Lumbar Spine

Question 1

What is mechanical back pain?

Answer 1

Recurrent or relapsing and remitting back pain with no neurological symptoms. Pain worse with movement, relieved by rest

Question 2

What patients commonly present with mechanical back pain?

Answer 2

Between 20-60, had several previous flare ups, no red flags

Question 3

What are some caused of mechanical back pain?

Answer 3

Obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA, spondylosis

Question 4

What is Spondylosis?

Answer 4

Where IV discs lose water content with age, resulting in less cushioning and increased pressure on face joints leading to 2’ OA

Question 5

What is the treatment of mechanical back pain?

Answer 5

Analgesia and physio if necessary. Back to work early, not bed rest

Question 6

In what cases of mechanical back pain may some patients benefit from spinal stabilisation surgery?

Answer 6

If single level (2 adjacent vertebrae) is affected by OA or instability, and if no improvement despite physio and conservative management, and no other adverse 2’ gain or behavioral issues affecting surgery outcome

Question 7

Where does an acute disc tear occur?

Answer 7

In the outer annulus fibrosis of an IVD

Question 8

After what does an acute disc tear classically happen?

Answer 8

Lifting a heavy object

Question 9

What makes pain characteristically worse in an acute disc tear?

Answer 9

Coughing (increases disk pressure)

Question 10

What is the treatment for an acute disk tear?

Answer 10

Usually resolves, takes 2-3 months. Analgesia + physio

Question 11

What can happen if a disk tear occurs to the gelatinous nucleus pulposis?

Answer 11

It can herniate or prolapse through the tear. It can 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

Question 12

Where is the commonest site for a PIVD?

Answer 12

Lower lumbar spine

Question 13

How does Sciatica occur?

Answer 13

PIVD in lower lumbar spine. L4/5/S1 nerve roots contributing to sciatic nerve and pain radiating to part of sensory distribution of sciatic nerve.

Question 14

How is the radicular pain in sciatica felt?

Answer 14

Neuralgic burning or severe tingling, often like severe toothache radiating down the back of the thigh to below the knee.

Question 15

In the lumbar spine which nerve root will be commonly compressed in relation to the vertebrae in the affected segment?

Answer 15

The nerve root corresponding to the lower of the two vertebrae (e.g. L3/4 prolapse > L4 entrapment>pin down medial ankle (L4), loss of quads power, reduced knee jerk

Question 16

What can occur in a very lateral disk prolapse?

Answer 16

Impingement of the nerve root corresponding to the vertebra above (L4/5 impingement presenting with an L4 nerve radiculopathy)

Question 17

What is the first line treatment of PIVD?

Answer 17

Analgesia, maintaining mobility and physio. Drugs for neuro pain can be used if leg pain severe

Question 18

What further treatment in secondary care may be needed for PIVD?

Answer 18

Surgery (discectomy) indicated when pain is not resolving despite treatment and signs suggesting specific nerve root involvement and +ve MRI evidence of compression.

Question 19

What can OA of the facet joints result in?

Answer 19

Osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica. Surgical depression, with osteophyte trimming, may be performed

Question 20

What is spinal stenosis?

Answer 20

Narrowing of the spinal canal. In lumbar spine with spondylosis, bulging discs and ligamentum flavum, osteophytosis caude equina has less space- multiple nerve roots are compressed/irritated

Question 21

Who will present with spinal stenosis?

Answer 21

Over 60yo, claudication in legs

Question 22

What is different about neurogenic claudication compared to vascular claudication?

Answer 22

Claudication distance is inconsistent, pain is burning, pain is less uphill (due to spinal flexion), pedal pulses preserved

Question 23

What is the treatment for spinal stenosis?

Answer 23

Conservative management, if ineffective with MRI evidence of stenosis, surgery may be performed