Degeneration, Lower Back Pain and Disc Prolapse Flashcards by Chloe Mackle

What are the common types of lower back pain?

Spondylogenic
Neurogenic
Viscerogenic
Vascular
Psychogenic

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Give some examples of causes of lower back pain

Mechanical back pain 
Disc herniation
Muscle strain
Ankylosing spondylitis 
IBD
Pyogenic sacroiliitis 
Herpes zoster 
Lymphoma

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What is the most common type of back pain?

Mechanical

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What are the features of mechanical back pain?

Positional
Activity may help
May have associated thigh pain

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Where is mechanical back pain managed?

In primary care

reassurance
explanation
simple analgesia regularly

Physiotherapy if it fails to settle
Can consider alternative therapy

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What percentage of mechanical back pain settles within 6 weeks?

90%

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What percentage of mechanical back pain recurs?

60%

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What percentage of people will suffer from back pain in their lifetime?

80%

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What is the cost of back pain to the NHS?

£900 million

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What percentage of GP referrals to orthopaedic outpatient clinics does back pain account for?

21%

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What percentage of all NHS costs does back pain account for?

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What physical movements are important in relation to back pain?

Bending and lifting

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How can back pain be managed generally?

Discourage the idea that it is a disease
Encourage general fitness - daily activity, reduce weight
Avoid activities that cause problems e.g. bending over, twisting, smoking
Understand the psychology
Understand the pathology

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What structures can become diseased and result in back pain?

Skin
Fascia
Fat
Muscle
Ligaments 
Tendons
Discs
Bone
Dura
Nerves
Abdominal contents
Vessels
Joints

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What is the management for persistent back pain?

Rehabilitation programme
Pain clinics
Surgery very rarely indicated

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What are the red flag symptoms of lower back pain?

Age of onset < 20 or > 55
Recent history of violent trauma
Constant, progressive, non-mechanical pain
Thoracic pain 
PMH of malignancy 
Prolonged use of corticosteroids 
Drug abuse
Immunosuppression 
HIV 
Systemic illness
Unexplained weightless 
Widespread neurological symptoms 
Structural deformity 
Fever

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What type of joint is at the intervertebral discs?

Secondary cartilaginous

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What is the largest avascular structure in the body?

Intervertebral disc

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What is the annulus fibrosis?

Tough outer layer of the intervertebral disc

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What is the nucleus pulposus?

Gelatinous core of intervertebral disc

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What damage can occur to the annulus and nucleus?

Annulus might tear
Nucleus might prolapse

Both can cause cord/nerve root compression

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Where does the cartilaginous end plate of each intervertebral disc attach to?

The body endplate of the vertebra

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How do the fibres of the annulus fibrosis run?

Obliquely and alternately between layers

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What do the fibres of the annulus fibrosis resist?

Rotational movements

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With what movements do discs fail?

Twisting movements

What does the nucleus pulpous consist of?

Water (88%) Collagen Proteoglycans

In what direction do disc prolapses usually occur?

Posterolateral

What are the normal changes in the intervertebral discs associated with normal ageing?

Decreased water content Disc space narrows Degenerative changes on x-rays and in facet joints Aggravated by smoking etc.

What is the pathology of intervertebral disc herniation?

Tearing of annulus fibrosis and protrusion of the nucleus Nerve root compression by osteophytes Central spinal stenosis Abnormal movement - spondylolysis, spondylolisthesis

In what directions can lumbar disc prolapse occur?

Lateral - compressed nerve root | Central - compressed roots with caudal equina syndrome

What are the features of nerve root pain?

``` Fairly common Limb pain worse than back pain Pain in a nerve root distribution - radicular Root tension and root compression signs Dermatomes and myotomes affected Most settle in 3 months (90%) ```

What is the treatment of nerve root pain?

Physiotherapy Strong analgesia Referral after 12 weeks Imaging

What disc problems can occur?

Bulge - common, mainly asymptomatic Protrusion - annulus weakened but still intact Herniation - through annulus, but in continuity Dequestration - desiccated disc material free in canal

What cervical level is most commonly affected by disc problems?

C5/6

What thoracic level is most commonly affected by disc problems?

Mid to lower levels T8-T12 75% Most at T11/12 Thoracic < 1% of intervertebral disc prolapses

In what directions can thoracic discs herniate?

Central Posterolateral Lateral

What lumbar level is most commonly affected by disc problems?

Usually L4/5 (45%) Followed by L5/S1 (40%) Then L3/L4 (10%)

In what direction do most disc herniations occur in the lumbar region?

Posterolateral

What are the features of cervical and lumbar spondylosis?

Common Degenerative changes at facet joints and discs If severe, can compress the whole cord, not just the nerve roots, causing myelopathy UMN signs in limbs e.g. increased tone, brisk reflexes

What part of the cervical spine transmits the vertebral artery?

Foramen transversarium

What cervical vertebrae do not have a bifid spinous process?

C1 and C7

What is C7?

The vertebra prominens, first easily palpable spinous process

Why might the patient lose consciousness in cervical spondylosis?

The vertebral artery passing through the foramen transversarium may get nipped/occluded

What movements do the facet joints of the lumbar spine mainly allow?

Flexion and extension

What do the intervertebral discs allow movement between?

Between the vertebrae

What are the main ligaments of the spine?

``` Anterior longitudinal ligaments Posterior longitudinal ligament Ligamentum flavum Interspinous and supraspinous ligaments Intertransverse ligament ```

What is cauda equina syndrome caused by?

Compression of the cauda equina, usually due to herniated lumbar disc Can also be caused by tumours, trauma, spinal stenosis, epidural abscess and iatrogenic causes

What are the clinical features of cauda equina syndrome?

Injury or precipitating event Location of symptoms - bilateral buttock and leg pain, varying dysaesthesia and weakness Bowel or bladder dysfunction - urinary retention +/- incontinence overflow Saddle anaesthesia, loss of anal tone and anal reflex High index of suspicion in post-op spinal patients with increasing leg pain in presence of urinary retention

What radiography should be done if suspecting cauda equina syndrome?

MRI | Lumbar CT or myelogram if MRI is contraindicated

What is the treatment of cauda equina syndrome?

Operative, within 48 hours

What does spinal claudication need to be distinguished from?

Vascular claudication

What are the features of spinal claudication?

Usually bilateral Sensory dysaesthesia Possible weakness, foot drop and tripping Takes several minutes to ease after stopping walking Worse when walking down hills, better when walking uphill or riding a bike

Why is spinal claudication worse when walking downhill?

The spinal canal becomes smaller in extension

What are the types of spinal stenosis?

Lateral recess stenosis Central stenosis Foraminal stenosis

What is the treatment progression of lateral recess stenosis?

Non-operative Nerve root injection Epidural injection Surgery

What is the treatment progression of central stenosis?

Non-operative Epidural steroid injection Surgery

What is the treatment progression of foramina stenosis?

Non-operative Nerve root injection Epidural injection Surgery

What is spondylolysis?

Defect of pars interarticularis

What is spondylolisthesis?

Anterior vertebral translation of cephalad vertebra on caudad vertebra

What are the features of spondylolysis?

Low back pain | Occasionally radicular symptoms

What investigations are done for spondylolysis?

CT MRI Bone scan

What is the treatment of spondylolysis?

Non-opertive Injection therapy Surgery

What are the features of spondylolisthesis?

Symptoms vary with type | Treatment depends on symptoms - conservative, lifestyle changes, surgery for persistent pain +/- nerve root entrapment

What is the radiographic (Meyerding) classification of spondylolisthesis?

``` Grade 1 - 0-25% Grade 2 - 25-50% Grade 3 - 50-75% Grade 4 - 75-100% Spondyloptosis - body of L5 vertebra sitting in front of S1 ```

What is the aetiological (Wiltse) classification of spondylolisthesis?

``` Congenital Isthmic Degenerative Traumatic Pathological ```