Lumbar Spine Flashcards
“Mechanical” back pain
recurrent relapsing and remitting back pain with no neurological symptoms.
pain is worse with movement (mechanical) and relieved by rest.
age of 20 and 60 and have had several previous “flare‐ups”.
No “red flag” symptoms are present.
“Mechanical” back pain causes
obesity
poor posture
poor lifting technique
lack of physical activity
depression
degenerative disc prolapse
facet joint OA
spondylosis
“Mechanical” back pain treatment
analgesia and physiotherapy.
reassure that they do not have a serious problem and should be urged to maintain normal function and return to work early.
bed rest is not advised as this will lead to stiffness and spasm of the back which may exacerbated disability.
Acute Disc Tear & causes
an occur in the outer annulus fibrosis of an intervertebral disc which classically happens after lifting a heavy object (eg lawnmower).
the periphery of the disc is richly innervated and pain can be severe.
Acute Disc Tear symptoms
Pain is characteristically worse on coughing (which increases disc pressure).
Symptoms usually resolve but can take 2‐3 months to settle.
Acute Disc Tear treatment
Analgesia and physiotherapy are the mainstay of treatment.
Sciatica/Lumbar Radiculopathy
If a disc tear occurs, the gelatinous nucleus pulposis can “herniate” or “prolapse” through the tear.
Disc material can press (impinge) on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution as well as reduced power in a myotomal distribution.
Reflexes (a test of sensory and motor function may also be reduced. (Note these are lower motor neurone signs).
Nerve Root Entrapment + treatment
OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica as previously discussed.
Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates.
Spinal stenosis & claudication
With spondylosis and a combination of bulging discs, bulging ligamentum flavum and osteophytosis, the cauda equina of the lumbar spine has less space – known as spinal stenosis ‐ and multiple nerve roots can be compressed / irritated.
Sufferers tend to over 60 and characteristically have claudication (pain in the legs on walking).
Spinal stenosis & claudication treatment
If symptoms fail to improve with conservative management (with physiotherapy and weight loss, if indicted) and there is MRI evidence of stenosis, surgery may be performed (decompression to increase space for the cauda equina) to help alleviate symptoms.
Cauda equina syndrome
very large central disc prolapse can compress all the nerve roots of the cauda equina producing a clinical picture known as cauda equina syndrome.
this is a surgical emergency as affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination.
prolonged compression can potentially cause permanent nerve damage requiring colostomy and urinary diversion and urgent discectomy way prevent this catastrophe.
Cauda equina syndrome- symptoms
bilateral leg pain, paraesthesiae or numbness and complain of “saddle anaesthesia” – numbness around the sitting area and perineum.
altered urinary function is typically urinary retention but incontinence can also occur. Faecal incontinence and constipation can also occur.
any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise
Cauda equina syndrome - treatment
A rectal examination (PR) is mandatory and it is considered negligent not to perform this is a cauda equine syndrome is missed.
Urgent MRI is required to determine the level of prolapse and urgent discectomy is required once the diagnosis is confirmed.
Even with prompt surgical intervention, significant number of patients have residual nerve injury with permanent bladder and bowel dysfunction.
Osteoporotic crush fractures
With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis.
A minority of patients go on to have chronic pain due to altered spinal mechanics.
Osteoporotic crush fractures treatment
Treatment is usually conservative.
However, some clinicians including interventional radiologists have tried balloon vertebroplasty (involves inserting a balloon into the vertebral body under fluoroscopic guidance, inflating a balloon to lift the corticies of the vertebral body) and injecting cement to fill the void) for patients with chronic pain with some good results obtained.
The long term results have not been fully evaluated and there is a small risk of neurological injury.
