Lumbar Pathologies Flashcards
Define ankylosing spondylitis
Chronic inflammatory autoimmune disease primarily affecting the spine and sacroiliac joint, and occasionally extra-articular structures, including the eye
characterised by inflammation at the sacroiliac joints, and of the junction between the vertebral bodies and the intervertebral disc, bony growth and eventual fusion of the vertebrae causing reduced movement
What gene increases the risk?
Human leukocyte antigen B27 (HLA-B27)
The majority of patients are HLA-B27 positive this is found within the white blood cells. This antigen has been associated with several autoimmune disorders, most commonly Ankylosing Spondylitis.
People with this antigen are at a higher than average risk of developing autoimmune diseases such as Ankylosing Spondylitis and reactive arthritis
How does it present clinically? (5)
Suspect ankylosing spondylitis in anyone with chronic or recurrent low back pain, fatigue, and stiffness, especially if:
First present with SI joint pain (Sacroilitis) /Low back pain; present for more than 3 months
Back pain and stiffness is inflammatory (rather than mechanical) and worse in the morning (lasting for more than 30 minutes), improving with movement (exercise) but not relieved by rest
Limited lumbar ROM - more limited as the disease progresses
Muscles spasms - of back muscles due to pain + inflammation
Lumbar hypolordosis & Thoracic hyperkyphosis - bent over posture; vertebrae fuse (extremely advanced)
Inflammation at insertions ligament, fascia, or joint capsule into bone (Enthesis)
Osteoporosis and related fracture (especially in post-menopausal women)
Enthesitis: Inflammation of the middle layer of the eye (Uveitis) - causing redness, light sensitivity, blurred vision and tearing
There is a family history of ankylosing spondylitis or spondyloarthritis
Pain and altered sensation - bony growths can also put pressure on the peripheral nerves as they exit the spine
Limitation of chest expansion relative to normal values for age and sex - due to inflammation of rib joints causing stiffness and painful breathing
Radiological criterion: Sacroiliitis on X-ray
How is it treated? (5)
Exercise - individualised, structured exercise programme, including stretching, strengthening and postural exercises and range of motion exercises for the lumbar, thoracic, and cervical spine
Massage
Hydrotherapy
NSAIDS
Pain relief
Walking aids - if person has severe difficulty with ADLs
Aetiology of AS
Age <45 (most common late teens-early 20s)
Male 3x > female
Genetic and environmental factors play a role in the development of AS
Although the aetiology is unclear, the presence of mononuclear cells (Lymphocytes and monocytes) in the acutely involved tissue suggests an immune response.
Research has shown more than 9/10 people with AS carry HLA-B27.
AS can affect people in very different ways, some can run marathons and others cannot get out of bed. Also some people never fuse and it can be a very unpredictable disease
Pathology of AS
When synovium is the affected tissue, there is an infiltration by macrophages and lymphocytes.
This is followed by replacement of the cartilage or fibrous tissue by a scar like fibroblast invasion which rapidly ossifies.
Cant be called an autoimmune disease unless you have the genetic marker picked up by a blood test
HLA-B27 complex codes for Major Histocompatibility (MHC) proteins and it is the interaction between these proteins and T cells that may be responsible for the pathogenesis of AS.
Other theories claim that aberrant peptide processing or misfolded HLA-B27 molecules may lead to autoimmune response
It has been theorised that enteric bacterial infections may trigger the onset AS
Differential diagnosis for AS
Degenerative or mechanical problems (most common) — for example degenerative disc disease, spondylosis, congenital vertebral anomalies, degenerative changes in the intervertebral (facet) joints, osteoarthritis of sacroiliac joints.
Fractures.
Infectious sacroiliitis.
Bone metastasis.
Primary bone tumours.
Spinal stenosis.
Hypermobility
Define spinal stenosis
A narrowing of the spinal canal (space within the vertebral foramen), causing pressure on the spinal cord.
Aetiology of spinal stenosis
Age > 50 (Younger people may also suffer this through birth defects)
Can occur at multiple sites within the spine, most commonly the cervical and lumbar spine.
Some people are born with a narrowed spinal canal, but most cases of spinal stenosis occur when something happens to narrow it
Causes of spinal stenosis
This narrowing happens as a result of:
Degenerative conditions (most common):
- *Bone Overgrowth:**
- *OA** the facet joints and the intervertebral discs. In this condition, bone spurs (osteophytes) grow into the spinal canal
Paget’s Disease can also cause overgrowth in bones.
Facet arthropathy:
Facet joints also enlarge as they become arthritic, which contributes to a decrease in the space available for the nerve roots
Thickened ligaments:
Ligaments of the spinal column, especially the ligamentum flavum, become stiff, less flexible, and thicker with age, which also contributes to spinal stenosis
Herniated disks:
Nucleus pulposus leaks out and presses on the spinal cord
Congenital stenosis:
Born with a spinal canal smaller than normal
Rare condition:
Such as tumours and metabolic conditions
Types of spinal stenosis
Central stenosis:
In the central spinal canal where the spinal cord or cauda equina are located
Lateral stenosis:
In the tract where the nerve root exits the central canal
Foraminal stenosis:
In the lateral foramen where the individual nerve roots exit out to the body
Clinical presentation of lumbar spinal stenosis
Weakness in a foot or leg
Neurogenic Claudication - pain or cramping in one or both legs after being stood for long periods of time or when walking (increasing the curve of the lumbar spine), sometimes eased by sitting or bending forwards.
Back pain
Clinical presentation of Cervical spinal stenosis
- Numbness/tingling in the hand, foot, arm or leg
- Weakness in the hand, foot, arm or leg
- Problems with walking or balance
- Neck pain
Define prolapsed/herniated disc
A disc herniates when part of the nucleus pulposus pushes through the outer edge of the disc and back toward the spinal canal. This puts pressure on the nerves of the spinal cord. Spinal nerves are very sensitive to even slight amounts of pressure, which can result in pain, numbness, or weakness in one or both legs
Clinical presentation of disc herniation
Leg or arm pain:
Herniated disk in the lower back (commonly L4-5, L5-S1), characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee.
Herniated disk is in the neck, the pain will typically be most intense in the shoulder and arm. This pain may shoot into your arm or leg when you cough, sneeze or move your spine into certain positions.
Numbness or tingling:
Pain is generally superficial and localized and is often associated with numbness or tingling.
Weakness:
In more advanced cases, motor deficit, diminished reflexes or weakness may occur. Clinically may be seen by stumbling, or impaired ability to lift or hold items.
