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Neurosurgery > Low Back Pain and Leg Pain > Flashcards

Low Back Pain and Leg Pain Flashcards

1
Q

What is the critical factor in assessing patients with lower back pain?

A

Features of lumbosacral nerve root compression such as leg pain or focal signs of neural compression in lower limbs.

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2
Q

What causes sciatica?

A 
Most commonly by lumbar disk prolapse
Osteophytes
Lumbar canal stenosis
Spondylolisthesis
Tumors are rare (cauda equina or pelvic)
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3
Q

What are the most common lumbar levels for disk prolapse?

A

L5/S1 (75%)

L4/L5 (20%)

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4
Q

Why is disc herniation usually in a posterolateral direction?

A

PLL (posterior longitudinal ligament) prevents direct posterior herniation.

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5
Q

What is the difference between a posteromedial prolapse vs lateral prolapse?

A
  • Posteromedial causes compression of lumbar nerve root passing across the disc to enter the neural canal BELOW pedicle
  • Posterolateral causes compression on nerve root passing beneath pedicle ABOVE prolapse
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6
Q

What is presentation of patient with sciatica?

A
  • Obvious discomfort
  • Lies tilted to side opposite of sciatica
  • Affected hip/knee slightly flexed taking pressure off stretched nerve
  • Pain worse with straining
  • Pain radiating to buttocks, posterolateral calf and foot (S1) or dorsum of foot and great toe (L5)
  • Pain along anterior thigh (L3)
  • Pain along anterior leg/shin (L4)
  • Check sphincter tone as large may cause cauda equina compression
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7
Q

Important PE in sciatica?

A
  • Straight leg testing on affected side
  • Head to toe neuro exam
  • Look for muscle wasting
  • For plantarflexion weakness ask to stand on tippy toes
  • DTRS!
  • Rectal exam
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8
Q

Segmental innervation of hip flexors, adductors, medial rotators?

A

L1, L2, L3

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9
Q

Segmental innervation of hip extensors, abductors, lateral rotators?

A

L5, S1

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10
Q

Segmental innervation of knee extensors?

A

L3, L4

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11
Q

Segmental innervation of knee flexors?

A

L5, S1

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12
Q

Segmental innervation of ankle dorsiflexors?

A

L4, L5

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13
Q

Segmental innervation of ankle plantarflexors?

A

S1, S2

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14
Q

Segmental innervation of foot invertors?

A

L5, S1

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15
Q

Segmental innervation of foot evertors?

A

L5, S1

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16
Q

Segmental innervation of intrinsic foot muscles?

A

S2, S3

17
Q

Describe clinical features of L5/S1 prolapsed disc?

A
  • Pain along posterior thigh with radiation to heel
  • Weakness of plantar flexion
  • Sensory loss in lateral foot
  • Absent ankle jerk
18
Q

Describe clinical features of L4/L5 prolapsed disc?

A
  • Pain along posterior or posterolateral thigh with radiation with radiation to dorsum of foot and great toe.
  • Paresthesia and numbness of dorsum of foot/great toe
  • Reflex changes unlikely
19
Q

Describe clinical features of L3/L4 prolapsed disc?

A
  • Pain in anterior thigh
  • Wasting of quads muscle
  • weakness of quads function and dorsiflexion of foot
  • Diminished sensation over anterior thigh, knee and medial aspect of lower leg
  • Reduced knee jerk
20
Q

Management of bulging disc vs. nucleus pulposus that has herniated out of disc space?

A
  • bulging disk does well with conservative treatment

- nucleus pulposus herniation most likely need surgery

21
Q

Describe important features of conservative treatment for disc herniation?

A
  • should improve in 7-10 days (bed rest), with NSAIDs
  • spinal manipulation is NOT recommended
  • Resolution 2/2 to resorption of prolapsed disc material, edema of nerve decreasing and possible adaptation of pain fibres to pressure.
22
Q

Investigations for low back pain?

A
  • Lumbar spine XR (excludes spondylolisthesis, tumor)
  • ESR (excludes systemic disease)
  • (MRI if does not improve after conservative management and/or if see Red Flags!)
23
Q

Indications for surgery re: low back pain?

A
  • Pain (incapacitating despite bed rest, recurrent pain despite adequate relief with bed rest)
  • Neurological deficit (significant weakness, increasing weakness)
  • Central disk prolapse (bilateral sciatica, sphincter disturbance, diminished perineal sensation – EMERGENCY!)
24
Q

Surgical options for disc prolapse?

A
  • Typically laminectomy, occasionally disc prolapse excision.
  • Bulging disk = conservative tx, sometimes percutaneous disectomy helpful
  • Bulging nucleus pulposus = percutaneous disectomy not helpful
25
Q

Prognosis following disc prolapse surgery?

A
  • Correlated to accuracy of pre-operative clinical evaluation
  • Good hx of sciatica
  • Good signs of nerve root irritation
  • Evidence of herniated disc
  • Patient well motivated
  • At surgery the nerve root is stretched by disc prolapse
  • 10-15% recurrence of prolapse
26
Q

Clinical presentation of lumbar stenosis?

A
  • Pain radiating into legs, esp standing or walking
  • Burning/achy quality
  • Relieved with sitting, bending forward
  • Similar to vascular claudication (must rule out!) pain when standing only = neurogenic claudication
27
Q

Exam findings of lumbar stenosis?

A
  • Sensory disturbance
  • Maybe muscle wasting
  • Check peripheral pulses
  • Mostly Hx
28
Q

Explain pathology of lumbar stenosis?

A
  • combo of canal stenosis and degenerative path such spondylosis with hypertrophy of facet joints, ligamentum flavum, osteophyte formation = narrowing of canal and bulging disks
  • most common L3/4, L4/L5
29
Q

Management of lumbar stenosis?

A
  • CT and MRI
  • Doesn’t respond well to conservative treatment
  • Surgical options: decompressive lumbar laminectomy over region of stenosis with decompression of lumbar theca and nerve roots
30
Q

What is the presentation of low back pain without leg pain or signs of nerve root compression?

A
  • acute, often following minor trauma
  • chronic or recurrent
  • usually due to soft tissue strain
  • if severe, may have included fracture or disc herniation
  • exam must exclude neuro sx
  • xray to exclude fracture (if severe)
31
Q

In cases where back pain is chronic or recurrent after minimal or trivial trauma what is common pathology?

A
  • lumbar spondylosis
  • spondylolisthesis
  • degenerative disc disease
32
Q

Uncommon low back pain without radicular signs includes:

A
  • spinal tumors
  • thoracic disc prolapse
  • spinal abscess
  • arteriovenous malformation
    (also consider pancreatic disease, aortic aneurysm, renal disease i.e. infection, tumor)
33
Q

What is spondylolisthesis?

A

Subluxation of vertebral body on another, usually L4 or L5.

34
Q

What is spondylolysis?

A

Defect in pars interarticularis, leads to spondylolisthesis

35
Q

Presenting features of spondylolisthesis?

A
  • Back pain w/ leg pain
  • “Tight” feeling in upper thighs
  • Vertebral slippage may compress lumbar nerve roots in neural foramen
36
Q

Treatment of spondylolisthesis?

A
  • Conservative therapy with short periods of bed rest during exacerbations of discomfort, gentle mobilizing exercises, NSAIDs
  • If still in pain, maybe lumbar brace
37
Q

Indications for spondylolisthesis surgery?

A
  • symptoms of lumbar stenosis
  • clinical features of nerve root compression unrelieved by conservative therapy
  • laminectomy to decompress nerve roots with spinal fusion
38
Q

Surgical treatment of Spondylolisthesis by grade?

A

Type 1 = surgery not good
Type 2 = typically benefit from surgery
Type 3/4 = greatly benefit

Neurosurgery (9 decks)

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