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MSK > Lecture 4 Lumbar Spine & Associated disorders > Flashcards

Lecture 4 Lumbar Spine & Associated disorders Flashcards

1
Q

What parts of the spine are immobile?

A

Sacral, coccygeal (these are fused, but the junction between these is mobile)

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2
Q

What is the length of the vertbral column?

A

Extends from the skull to the apex of the coccyx.

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3
Q

What % of the vertebral column is from the intervertebral discs?

A

25%

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4
Q

What parts of the spine are mobile?

A

Cervical and lumbar.

Thoracic spine is less mobile as they are joined by the ribs to the sternum.

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5
Q

What are the curvatures of the spine?

A

Primary kyphotic-concave anteriorly
(primary refers to the curves that develop in the fetal period)
-thoracic & sacral

Secondary lordotic-concave posteriorly
(secondary refers to the curves that develop during childhood, associated with lifting the head and sitting)
-cervical & lumbar

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6
Q

What is the purpose of the spinal curves?

A

They balance each other forming a stable system that maintains the centre of gravity.

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7
Q

What happens to the size of the vertebral bodies inferiorly?

A

Increase in size.

-compression forces increase

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8
Q

Why are the sacral vertebrae fused, widened adn concave anteriorly?

A

To transmit the body weight through the pelvis to the legs, and withstand compression.

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9
Q

What are the functions of the vertebral column?

A
  • central bony pillar which supports skull, pelvis, upper limbs, thoracic cage
  • protects spinal chord and cauda equina
  • provides role in posture and locomotion
  • bone marrow is an important site of haematopoiesis
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10
Q

What is the typical structure of a lumbar vertebra?

A
  • kidney shaped vertebral body (largest part, major load bearing structure)
  • vertebral arch posteriorly (spinal chord runs through)
  • vertebral foramen
  • 7 processes (posterior)
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11
Q

What is the conus medullaris?

A

Lower end of the spinal chord- where it finishes

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12
Q

What does the vertebral body contain?

A

90% cancellous bone
-reduces weight and permits haematopoiesis
-
10% cortical bone

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13
Q

What are the vertebral end plates?

A

Superior and inferior articular surfaces of the vertebral body.
-covered in hyaline cartilage

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14
Q

How are the vertebral bodies connected?

A

Intervertebral discs

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15
Q

How much of the load is carried by posterior elements?

A

1/3

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16
Q

What is the vertebral arch formed from?

A

2 laminae & 2 pedicles

  • lamina connect the transverse process to the spinous process
  • pedicle connects the transverse process to the vertebral body
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17
Q

What is the function of the transverse and spinous processes?

A

Provide an attachment point for muscles and ligaments to control the position of the vertebral bodies.

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18
Q

What are the articular processes?

A

They project from the lateral aspects of the laminae, they are concave (vertebral notch)
Inferior: project caudally
Superior: project cephalically
They articulate with adjacent vertebrae providing a mobile joint.

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19
Q

What are the 7 processes?

A
  • 2 transverse processes
  • 2 superior articular processes
  • 2 inferior articular processes
  • 1 spinous process
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20
Q

What is the vertebral notch?

A

The concavity in the articular processes.

-therefore each vertbrae has 2 superior and 2 inferior notches

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21
Q

What is the facet (zygapophyseal) joint?

A

Formed between adjacent superior and inferior articular processes.

  • synovial joint lined with hyaline cartilage
  • prevents forward-backward (antero-posterior) displacement of vertebrae
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22
Q

What is the amount of flexion/rotation at facet joints in lumbar region determined by?

A

Inclination of articulating surfaces (facets)

Lumbar: 90 degrees to transverse plane, 45 degrees from coronal plane

  • superior facets lie posteromedially
  • inferior facets lie anterolaterally
  • permits flexion/extension/rotation/lateral flexion

Orientation of facet joints changes at lumbosacral junction where inferior facet faces anteriorly (prevents vertebral column sliding anteriorly on the sacrum)

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23
Q

What is the axial plane?

A

Transverse plane

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24
Q

What is mechnicalback pain, and what is it characterised by?

A

It is characterised by pain when spine is loaded, worsens with exercise, relieved by stress.

  • very common
  • intermittent
  • triggered by innocuous activity
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25
Q

What are the risk factors for mechanical back pain?

A
  • obesity
  • poor posture
  • sedentary lifestyle
  • poor seating
  • incorrect manual handling
  • deconditioning of paraspinal muscles
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26
Q

What is disc generation and what does it cause?

A

Nucleous pulposus dehydrates with age.

  • causing bulging of discs
  • alteration of stress on the joints
  • osteophytes (bony spurs) called syndesmophytes develop adjacent to the end plates
  • increased stress on facet joint develop osteoarthritic changes
  • as arthritis develops and disc height shrinks, intervertebral foramina decrease in size
  • compression of spinal nerves:nerve/radiular pain
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27
Q

Why is arthritis painful?

A

Because the facet joints are innervated by the meningeal branch of the spinal nerve.

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28
Q

How does a slipped disc occur?

A
  1. disc degeneration (dehydration and bulging)
  2. Prolapse (protrusion of nucleus pulposus into spinal canal, contained within rim of annulus fibrosus)
  3. Extrusion (NP breaks through annulus fibrosus but still contained within disc space)
  4. Sequestration (NP separates and enters the spinal canal)
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29
Q

How do you name the intervertebral discs?

A

Disc b/w L4 & L5 is the L4/5 disc.

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30
Q

What are the most common site for a slipped disc?

A

L4/5 disc.
L5/S1 disc.
Due to mechanical loading at these points.

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31
Q

Where are the nerve roots most vulnerable?

A
  • where they cross the intervertebral disc

- where they exit the spinal canal via the intervertebral foramen

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32
Q

What is the intervertebral foramen?

A

It allowsthe dorsal/ventral rami out. They leave on either side.

33
Q

What are the different types of slipped disc (herniation of an intervertebral disc)?

A

96% of cases: posterolaterally (lateral to the posterior longitudinal ligament). PARACENTRAL PROLAPSE
-traversing nerve root most at risk
2% of cases: FAR LATERAL
-exiting nerve root is most at risk
2% of cases: CENTRAL- directly towards spinal chord
-risk of cauda equina syndrome

34
Q

What is the exiting and traversing nerve root?

A

Exiting: nerve root that emerges from the spinal canal the same time as the intervertebral disc.
Traversing: nerve root that emerges at the level below

35
Q

What is radicular leg pain?

A

Sciatica

-pain caused by irritation/compression of one ormore of the nerve roots that contribute to the sciatic nerve

36
Q

What are the symptoms and causes of sciatica?

A

Causes: slipped disc, osteophytosis
Symptoms: pain in back and buttock, radiates to the dermatome supplied by the affected nerve root
(if nerve compression also causes paraesthesia, this will only be experienced in affected dermatome)

37
Q

What is cauda equina syndrome?

A

‘Canal filling disc’ due to central prolapse, compressing the lumbar & sacral nerve roots.
5% due to disc prolapse

38
Q

Causes of cauda equina syndrome:

A
  • disc prolapse
  • tumour
  • spinal infection/abcess
  • spinal stenosis secondary to arthritis
  • spinal haemorrhage
  • ankylosing spondylitis (inflammed vertebrae, causing them to fuse)
39
Q

Symptoms of cauda equina syndrome:

A
  • bilateral sciatica
  • saddle anaesthesia (perianal numbness)
  • painless retention of urine
  • urinary/faecal incontinence
  • erectile dysfunction
40
Q

How do you treat cauda equinaand what happens if you don’t diagnose it quick enough?

A

Surgical decompression within 48 hours.

  • chronic pain
  • performing self-catherterisation
  • faecal incontinence/manual evacuation
  • loss of sensation in lower limb/weakness, requiring a wheelchair
41
Q

What is spinal canal stenosis?

A

Abnormal narrowing of the spinal canal, compressing the spinal chord/nerve roots.

42
Q

Causes and symptoms of spinal canal stenosis:

A 
Affects the elderly.
Symptoms depend on the region of the chord that are affected. Lumbar is most common, then cervical.
Causes
-disc bulging
-facet joint osteoarthritis
-ligamentum flavum hypertrophy
-compression fractures 
-trauma
-spondylolisthesis
Symptoms
-discomfort standing
-bilateral symptoms
-numbness/weakness below or at level of stenosis
-neurogenic claudication
43
Q

What is neurogenic claudication?

A

Symptom.
Patient reports pain/pins and needles of prolonged standing/walking-limp
-results from compression of the spinal nerves
-leads to venous engorgment of nerve roots during exercise (veins in spinal canal swell,leading to reduced arterial inflow and arterial ischaemia)
-

44
Q

What is spondylolisthesis?

A

Anterior displacement of vertebra above the vertebra below.
Many types:
-congenital: congenital instability of the facet joints
-trauma: acute fractures
-pathological: infection/malignancy
-iatrogenic: caused by surgical intervention

45
Q

What is the isthmic type of spondylolisthesis?

A

Defect in the pars interarticularis (b/w superior/inferior articular processes)

46
Q

What is the difference between spondylolysis and spondylolisthesis?

A

Spondylolysis is a fracture in the pars interarticularis without displacement.
Spondylolisthesis is the anterior displacement (can remain asymptomatic but most complain of discomfort)

47
Q

How do you treat spondylolisthesis?

A

Using screws and rods to stabilise the spine.

48
Q

How do you detect spondylolisthesis?

A
  • outline of ‘scotty dog’: with collar is the fracture in the oblique view
  • grossly-displaced vertebrae can be identified by a large step in the smooth vertebral curve
49
Q

What is a lumbar puncture?

A

Withdrawal of fluid from the subarachnoid space of the lumbar cistern (space around the cauda equina in spinal chord).

  • performed with patient on side and back/hips flexed up into a ball so there is flexion of vertebral column
  • facilitates insertion of needle in midline b/w L3/4/5 (no danger of damaging spinal chord), skin is anaethetised
  • can be found by locating the iliac crests (top of pelvis)
  • needle 4-6cm, longer in obese, it pops through ligamentum flavum, the dura, then the arachnoid and enters the lumbar cistern (subarachnoid space)
  • detects CNS disorders e.g. meningitis, MS
50
Q

What are the functions of the ligaments in the vertebral column?

A
  • provide stability by preventing excess movement
  • most effective in supporting loads that are applied in the same direction to which their fibres run in
  • store energy, provide resistance by developing tension, but under compression the ligaments can buckle
51
Q

What is the anterior/posterior longitudinal ligament?

A

-lie immediately anterior/posterior to vertebral bodies

  • anterior is stronger, it runs from C1 to sacrum and is untied with the periosteum of vertebral bodies. Over the intervertebral discs it is loosely attached and mobile
  • anterior prevents hyperextension bending backward)
  • posterior runs from C2 to the sacral canal. Prevents hyperflexion (bending forward).
  • reinforces annulus fibrosus centrally so prolape of intervertebral disc occurs lateral to the ligament
52
Q

What is the ligamentum flavum?

A
  • high elastin content
  • appears yellow
  • between laminae of adjacent vertebrae
  • becomes stretched during flexion
53
Q

What are the interspinous ligaments?

A
  • weak sheets of fibrous tissue
  • unite spinous processes along adjacent borders
  • increase stability by resisting hyperflexion
  • fuse posteriorly with the supraspinous ligament
54
Q

Where are the interspinous ligaments most highly developed?

A

In the lumbar region.

55
Q

What is the supraspinous ligament?

A
  • runs along tips of adjacent spinous processes
  • strong band of fibrous tissue
  • lax in extension
  • taught in flexion
56
Q

What happens when you flex the spine?

A
  • posterior longitudinal ligament,ligamentum flavum, interspinous ligaments, supraspinous ligaments are all under tension
  • vertebral bodies, intervertebral discs, anterior longitudinal ligament are under compression
57
Q

How much body weight is transmitted through the vertebral bodies and facet joints when young/old?

A

Young: 80% through vertebral bodies, 20% through facet joints
Old: 65% through vertebral bodies, 35% through facet joints (as the nucleus pulposus decreases in size)
-increased stress on facet joints can lead to osteoarthritic changes

58
Q

What is good manual handling?

A
  • hold load close to body
  • if you hold load far away from your body, force is multiplied many times through the spine leading to greater risk to injury
59
Q

What is the coccyx and thesacrum?

A

Coccyx: 4 fused vertebrae
-easily fractured when you fall on your buttock
Sacrum: 5 fused vertebrae

60
Q

What are the sacroiliac joints?

A

Joining of the sacrum to the pelvis/iliac crests

61
Q

What is the sacral hiatus?

A

Central canal of vertebral column continues until S4 where it ends as the sacral hiatus.

62
Q

What do the nerves that compose the cauda equina innervate?

A
  • pelvic organs

- lower limbs

63
Q

Where does the dural sac terminate?

A

S2

It contains the proximalparts of the nerve fibres from the cauda equina.

64
Q

How do sacral nerve fibres leave?

A

Via the 4 pairs of posterior sacral foramina.

65
Q

What is the filum terminale?

A

Continuation of the pia mater from the conus medullaris of the spinal chord to the first segment of the coccyx.

66
Q

What shape is the vertebral column in the fetus?

A

C-shaped (concaves anteriorly-kyphosis)

  • primary curvature
  • retained in the thoracic,sacral, coccygeal regions
67
Q

What happens when a child starts to lift their head?

A

Cervical spine develops posterior concavity (lordosis)

68
Q

When does the lumbar lordosis develop?

A
  • during crawling the anterior concavity straightens out

- upon standing & walking it develops posterior concavity

69
Q

What are the secondary curvatures?

A

Lumbar
Cervical
(lordosis)
-develop due to the intervertebral discs becoming more wedged

70
Q

What happens during pregancy?

A

Lumbar lordosis becomes more defined due to additional abdominal mass,so centre of gravity drags you forward.

71
Q

What is senile kyphosis?

A

Disc atrophy means the curvatures start to disappear.

-continuous primary curve is restablished

72
Q

What happens with increasing age?

A
  • annulus fibrosis degenerates
  • nucleus pulposus loses tugor
  • account for loss of height
  • patients also experience osteoporotic vertebral compression fractures, resulting is wedge shaped vertebrae
73
Q

Where does the centre of gravity pass through the vertebral column?

A 
C1/2
C7/T1
T12/L1
L5/S1
These are the weak points where pathology tends to develop.
74
Q

How do we prevent falling?

A

Curvatures of the spine are balanced.

75
Q

What types of imaging are used on the spine?

A

CT: more detailed images of bone than X-Ray, multiple planes
MRI: can see tumours, infections, disc herniations, stenosis
Isotope bone scans: identify inflammatory process (tumour/infection/fractures not seen on X-ray-occult (hidden)

76
Q

What is the structure of the intervertebral discs?

A

Annulus fibrosus

  • peripheral
  • shock absorber
  • lamellae of bands or collagen in different orientations (outer are type 1 collagen, inner are fibrocartilaginous)
  • avascular & aneural
  • highly resistant under compression
77
Q

Why does the vertebral body tend to fracture?

A

Because the intervertebral discs are stronger, so under compression the vertebral body tends to fracture.
(intervertebral discs only strong under axial compression, not at load applied at an angle, so keep spine straight when lifting)

78
Q

What is the nucleus polposus and where is it located?

A

Remnant of the notochord. Gelatinous and contains type 2 collagen

  • high oncotic pressure
  • during day water is squeezed out due to mechanical pressure
  • located centrally in children
  • posteriorly located in adults
79
Q

What are the orientation of the facet joints in cervical vertebrae?

A
  • 45 degrees to transverse (axial) plane
  • in coronal plane
  • superior processes facing up
  • inferior processes down
  • permits flexion/extension/lateral flexion/rotation

MSK (12 decks)

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