Lecture 4 - Spinal conditions

Question 1

Mechanical back pain

Answer 1

Pain when spine is loaded

Worst with exercise and better with rest.

Question 2

Risk factors for mechanical back pain

Answer 2

Obesity
Poor posture
Sedentary lifestyle 
Weak core muscles 
Incorrect manual handling

Question 3

Marginal osteophytosis

Answer 3

Bony spurs (syndesmophytes) develop adjacent to the endplates of the vertebral discs

Due to nucleus pulposus dehydration with age

Therefore decrease in height of disc, bulging and changes to load stresses on joints.

Increased load on facet joints - osteoarthritic changes

Question 4

Why does arthritis cause pain

Answer 4

Facets supplies by meningeal branch of spinal nerve

Decreased size of intervertebral foramen therefore compression of spinal nerves

Causes radicular/nerve pain

Question 5

Slipped disc

Answer 5

Herniation of an intervertebral disc compresses spinal nerve

Question 6

4 stages of disc herniation

Answer 6

1. Disc degeneration
2. Prolapse
3. Extrusion
4. Sequestration

Question 7

Disc degeneration

Answer 7

Chemical changes associated with ageing causing the nucleus pulposus to dehydrate and bulge

Question 8

Prolapse

Answer 8

Protrusion of the nucleus pulposus occurs causing slight impingement into the spinal canal

Nucleus pulposus still contained within annulus fibrosus

Question 9

Extrusion

Answer 9

Nucleus pulposus breaks through the nucleus fibrosus but still contained in disc space

Question 10

Sequestration

Answer 10

The nucleus pulposus separates from the main body of the disc and enters the spinal canal

Question 11

Common sites for slipped disc

Answer 11

L4/L5

L5/S1

Question 12

Where are the nerve roots most susceptible to damage?

Answer 12

1. When leaving the spinal canal in the neural foramen laterally
2. Where they cross the intervertebral disc paracentrally

Question 13

What is the most common direction for nucleus pulposus herniation?

Answer 13

Posterolaterally - lateral to the posterior longitudinal ligament

Therefore compresses spinal nerve root within the intervertebral foramen

Question 14

Paracentral prolapse

Answer 14

Herniation of the nucleus pulposus posterolaterally which compresses the spinal nerve in the intervertebral foramen

96% of cases

Question 15

What is the risk of central herniation?

Answer 15

Cauda equina syndrome

Question 16

What nerve is at risk of compression in a far lateral herniation

Answer 16

Exiting nerve root - emerges at the same level as the intervertebral disc

Question 17

What nerve is at risk in a posterolateral herniation

Answer 17

Traversing nerve root- emerges at a level below the intervertebral disc

Question 18

In a paracentral herniation of the L4/L5 disc, what nerve root is compressed?

Answer 18

L5

Question 19

Sciatica

Answer 19

Pain caused by irritation or compression of one or more of the sciatic nerve roots (L4 - S3)

Pain in the back and buttocks and radiates to the dermatome supplied by the affected nerve root.

Question 20

Causes of sciatica

Answer 20

Marginal osteophytosis

Slipped disc

Question 21

L4 Sciatica distribution of pain

Answer 21

Anterior thigh
Anterior Knee
Medial Leg

Question 22

L5 Sciatica distribution of pain

Answer 22

Lateral thigh
Lateral leg
Dorsum of foot

Question 23

S1 Sciatica distribution of pain

Answer 23

Posterior thigh
Posterior leg
Heel
Sole of foot

Question 24

Nerve compression in sciatica

Answer 24

Only causes paraesthesia in the affected dermatome

Question 25

Cause of cauda equina syndrome

Answer 25

• Centrally prolapsed disc - canal filling disc
• Tumours of the vertebral column or memninges
• Spinal infection
• Absesses
• Spinal stenosis secondary to arthritis
• Vertebral fracture
• Spinal haemorrhage
• Late-stage ankylosing spondylitis

Compresses the lumbar or sacral nerve roots within the spinal canal

Question 26

5 Red flag signs of cauda equina

Answer 26

1. Bilateral sciatica
2. Perianal numbness
3. Urinary/ faecal incontinence
4. Painless urine retention
5. Erectile dysfunction

Question 27

How to treat cauda equina syndrome?

Answer 27

Emergency surgical decompression with 48 hours of teh onset of sphincter symptoms

(otherwise poor prognosis)

Question 28

Spinal canal stenosis

Answer 28

Abnormal narrowing of the spinal canal that compresses the spinal cord or the nerve roots

Question 29

Causes of spinal canal stenosis

Answer 29

Combination of:

• Disc bulging
• Facet joint osteoarthritis
• Ligamentum flavum hypertrophy

Also get:

• Compression fractures of the vertebral bodies
• Spondylolisthesis
• Trauma

Question 30

What is the most common spinal cord stenosis and how does it present?

Answer 30

Lumbar stenosis

Discomfort while standing 
Discomfort/pain in the lower limb 
Bilateral symptoms 
Numbness and weakness at or below level of stenosis 
Neurogenic claudication

Question 31

Neurogenic claudication

Answer 31

Pain or pins and needles in legs on prolonged standing and on walking

Radiating in a sciatic distribution

Question 32

Causes of neurogenic claudication

Answer 32

Compression of spinal nerves as they emerge from the lumbosacral spinal cord

Venous engorgement of the nerve roots during exercise

Reduced arterial blood flow- transient ischaemia

Question 33

What relieves neurogenic claudication?

Answer 33

Rest
Flexion of spine
Change in position

Question 34

Spondylolisthesis

Answer 34

Anterior displacement of the vertebrae above

Question 35

Causes of spondylolisthesis

Answer 35

Congenital - unstable facet joints
Degenerative - arthritis and joint remodelling 
Trauma 
Pathological - infection/malignancy
Iatrogenic

Question 36

Lumbar puncture (L3/L4)

Answer 36

Withdrawal of fluid from the subarachnoid space of the lumbar cistern

Patient lying on the side with back and hips flexed

L3/L4 located by identifying the highest point of iliac crest