Lumbar Spine

Question 1

Scoliosis

Answer 1

Curvature of the spine.
Can be postural or structural

Postural Scoliosis-
- secondary condition to a condition outside the spine (short leg or pelvic tilt etc)

Structural Scoliosis-
- non correctable deformity of the spine.

Most cases of scoliosis have no obvious cause so they are idiopathic.

• congenital or osteopathic (due to bony abnormalities)
• Neuropathic or myopathic (associated with some muscle dystrophies)

CP:
- deformity
- pain is a rare complaint (would suggest something more alarming)

Question 2

Idiopathic Scoliosis

Answer 2

Late onset (10+)
Early onset juvenile (4-9)
Early onset infantile (3 and less)

Late onset-
- most common (90% of cases)
- girls mostly affected
- likely to occur during a growth spurt

Early onset juvenile-
- uncommon
- characteristics similar to late onset, but prognosis is worse and surgical correction may be needed before puberty

Early onset infantile-
- rare
- 90% of cases resolve on their own.
- However, progressive curves can become very severe and this may, in addition cause cardiopulmonary dysfunction

Oseopathic (congenital) scoliosis-
- caused by bony abnormality

Neuropathic and myopathic scoliosis:
- caused by neuromuscular conditions-
- cerebral palsy
poliomyelitis
- syringomyelia

In severe cases, the greatest problem is loss of stability and balance, which may make even sitting difficult or impossible

Question 3

pyogenic infection

Answer 3

Bacterial infection, usually staphylococcus aureus (responsible for 50-60% of cases)
Travels to the spine via the blood stream.
Uncommon in spine

Infection limited to just intervertebral discs- discitis

CP:
- localised intense pain, muscle spasm and restricted movement
- tenderness over affected vertebrae
- systemic signs like tachycardia may be present
- abscess formation may occur, pus may secrete into spine causing severe pain and decreased ROM
- difficult to diagnose in children- stiffness in back may be a concerning sign

Question 4

Tuberculosis

Answer 4

Spine most common site for TB

• blood Bourne infection, settles in vertebral body
• bone destruction and caseation can occur, with infection spreading to the disc space and other vertebrae
• abscess formation can occur
• affected vertebral bodies may collapsed and create a kyphos. Severe kyphosis of TSP can occur
• major risk of cord damage, due to pressure by the abscess

CP:
- kyphos may be main symptom
- Local tenderness in back
- spinal movements restricted
- sensory changes in limbs can occur
- concurrent pulmonary TB

Potts paraplegia:
- usually within 2 years of disease onset
- due to pressure by inflammatory oedema, an abscess, caseous material, granulation tissue or sequestra
- pt presents with lower limb weakness, upper motor neurone signs, sensory dysfunction and incontinence

Late onset paresia-
- due to direct cord compression from increasing deformity, or (occasionally) vascular insufficiency of the cord

AIDS and spinal TB:
- HIV can increase the risk of TB and other infections

Question 5

Ankylosing Spondylosis

Answer 5

Condition where the spine becomes inflamed, and over time it can cause some of the bones of the spine to fuse.

causes:
- cause unknown
- genetics- pt who has HLA-B27 gene are more likely to contract Ankylosing Spondylosis

AG:
- affects men more than women

RF:
- HLA-B27

CP:
- back pain and stiffness
- pain and swelling in other parts of the body- caused by inflammation of the joints
- extreme tiredness

prognosis:
- heart problems
- compression fractures
- eye inflammation

Question 6

Spondylolisthesis

Answer 6

Occurs when one of the vertebrae in the spine slips out of place.
Occurs in 4%-6% of population

causes:
- overextending of spine in young athletes
- genetics, as people may have thinner vertebrae
- in older people, degeneration causes spondylolisthesis

AG:
- young athletes
- older people (degeneration)

RF:
- athletes
- genetics
- age

CP:
- Dysplastic spondylolisthesis:
– occurs in children
– usually painless, may notice protruding abdomen

• lytic spondylolisthesis:
  – most common
  – occurs in adults
  – intermittent backache
  – pain exacerbated by excercise or strain
  – a step can be felt running fingers down spine of pt
  – buttocks flat, sacrum extends to waist, and transverse loin creases may be prominent
• degenerative spondylolisthesis:
  – occurs in adults 40+
  – caused by degeneration
  – long standing backache due to facet joint arthritis
  – spinal claudication can occur due to narrowing of the spinal canal (caudal equina)

prognosis:
- most of time, non surgical treatments can relieve symptoms
- for severe spondylolisthesis, surgical intervention is usually successful

Question 7

Spinal Stenosis

Answer 7

Narrowing of spinal canal
Long term consequence of degeneration and OA

causes:
- degeneration- formation of osteophytes
- herniated discs
- spinal injuries
- spondylolisthesis increases chances
- congenital- pt can be born with small pedicles
- tumors

age group:
- people over age of 50
- young people have a higher risk if they have scoliosis or other spinal problems

RF:
- spondylolisthesis occurring
- spinal canal being naturally small

CP:
- backache
- numbness and parasthesia in lower limb (spinal claudication can occur)
- dermatomal distribution indicates which levels of spinal nerves are affected

Question 8

Herniated disc

Answer 8

Prolapse of annulus fibrosis of the lumbar disc into spinal canal.
Or rupture of annulus fibrosis with excretion of nucleus pulposus.
This will press on spinal cord (central) or nerve roots (lateral) causing symptoms.

causes:
- degeneration can make discs weaker meaning they can take less tensile stress making herniation of the disc more likely.
- trauma injury, like a car accident, lifting something heavily and causing the disc to herniate

CP:
- lumbar disc herniation doesn’t usually reveal lower back pain
- central prolapse would cause central prolapse
- buttock and radicular leg pain, dermatomal distribution will show which nerve root is affected

prognosis:
- most do not require surgical intervention

Question 9

Lumbar Sacral Strain

Answer 9

Injury that causes lower back pain
Injury when there is either acute or chronic micro trauma to the tissues.
This causes inflammation and pain to tissues, but do not destabilise the spine

causes:
- pushing and pulling sports, weight lifting, football etc
- sports that require sudden twisting of the lower back, tennis, rugby, football
- excessive lower back curvature, forward-tilted pelvis, weak back, or abdominal muscles, tight hamstrings.

AG:
- younger active people
- 20-50
- unusual in adolescent, warrants further investigation

CP:
- may present with acute episode of trauma or a prolonged and persistent increase in the intensity and duration of their existing lower back pain.
- sudden lower back pain
- pain exacerbated by movement
- may report tightness along lumbosacral paraspinal muscle region
- spasms in lower back
- lower back sore to touch

prognosis:
- 6 week non operative management
- if pain doesn’t increase by 50% over this time, then additional diagnosis should be considered