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RB Y2 MSK 03 - Spine and Paediatric Orthopaedics > Lumbar Spine > Flashcards

Lumbar Spine Flashcards

1
Q

upper motor neuron signs

A

inc muscle tone (spasticity), weakness, hyperreflexia

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2
Q

what is a sign of hyperreflexia

A

Babinskis sign - big toe is extended rather than flexed upon appropriate stimulation

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3
Q

lower motor neuron signs

A

muscle weakness, wasting (atrophy), absence of reflex

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4
Q

how do spinal nerves arise

A
  • begin as anterior (motor) and posterior (sensory) nerve root, arise from spinal cord and unite at intervertebral foramina, forming a single mixed spinal nerve
  • The spinal nerve then leaves the vertebral canal via the intervertebral foramina and divides into two:
  • The posterior rami supply the nerve fibres to the synovial joints of the vertebral column and the deep muscles of the back, and the anterior rami supply nerve fibres to much of the remaining body (posterior = dorsal). ​
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5
Q

where does the mixed spinal nerve splt into posterior and anterior rami

A

intervertebral foramina

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6
Q
A
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7
Q

at what level does the spinal cord end

A
  • L1/2 - tapers off forming the conus medullaris
  • the spinal nerves that arise from here are called the cauda equina
  • therefore, there is no spinal cord in the lumbosacral spine - problems here tend to arise as nerve root problems not spinal cord injury
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8
Q

which nerve root is commonly affected in disc prolapse

A
  • traversing nerve root
  • in far lateral disc prolapse the exiting nerve root can be affected
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9
Q

how are nerve roots named in the cervical and lumbar spine

A

In the cervical spine, the nerve root is named according to the lower spinal segment that the nerve root runs between, e.g. nerve at C5-6 level is called C6 nerve root.

In the lumbar spine, the nerve roots are named according to the upper segment that the nerve runs between.

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10
Q

what does nerve root compression cause

A

radiculopathy (pinched nerve) that results in pain down the dermatome of that nerve, and weakness ina ny muscle supplied (myotome) with reduced or absent reflexes

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11
Q

what is nerve root compression called in the lower leg

A

sciatica (L4-S3)

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12
Q

sciatica - L3/4 prolapse

A

(L4 entrapment)

pain down to medial ankle, loss of quadriceps, reduced knee jerk

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13
Q

sciatica - L4/5 prolapse

A

pain down dorsum of foot, reduced power extensor hallicus longus and tibialis anterior

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14
Q

sciatica - L5/S1 prolapse

A

pain to sole of foot, reduced pwoer plantarflexion, reduced ankle jerks

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15
Q

what can a very lateral disc prolapse cause

A

impingement of the exiting nerve root

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16
Q
A

A – laterally placed prolapse affects exiting nerve root (e.g. exiting L4).

B – central prolapse affects traversing nerve root (e.g. traversing L5).

C – central prolapse leads to cauda equina.

D – formation of osteophytes in the lateral canal will also lead to root compression.

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17
Q

treatment of disc prolapse

A

analgesia, maintaing mobility and physio are first line

drugs for neuropathic pain (gabapentin) in severe cases

very occasionally surgery (discectomy)

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18
Q

within what time period should disc prolapse resolve

A

3 months

after this surgery (discectomy) may be considered

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19
Q

chance fractures

A
  • seatbelt fractures
  • sudden flexion of the vertebral body disrupts the posterior elements
  • very unstable and associated with intra-abdominal injuries
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20
Q
A

chance fracture

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21
Q

where is lumbar puncture and spinal anaesthesia performed

A

highest point of iliac crest - L4

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22
Q

myelopathy

A
  • describes any neurologic deficit related to the spinal cord
  • causes upper motor neuron signs eg Babinski sign
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23
Q

babinski sign

A

the big toe is extended rather than flexed on appropriate stimulation

upper motor neuron symptom

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24
Q

spondylosis

A

broad term meaning degeneration of the spinal column

intervertebral discs lose water content with ageing leading to overloading of the facet joints

most commonly occurs L45 and L5/S1

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25
Q

what can spondylosis lead to

A

secondary OA

26
Q

clinical features of spondylosis

A

pain when flexing back (weight load on the facet joints) and relief when flexing forward

27
Q

are MRIs diagnostic for bulging discs

A

no - 60% of people >45 have bulging discs on MRI

28
Q

mechanical back pain

A

recurrent relapsing and remitting back pain with no neurological symptoms

worse with movement and relieved by rest

no red flag symptoms present

29
Q

causes of mechanical back pain

A

obesity

depression

poor lifting technique

poor posture

degenerative disc prolapse

OA

spondylosis - 2y OA

30
Q

treatment of mechanical back pain

A

analgesia and physio

bed rest not advised

small minority of patients benefit from surgery

31
Q

acute disc tear

A

can occur in the outer annulus fibrosus of the interverterbal disc

very painful as it has a rich innervation

32
Q

how does an acute disc tear present

A

classically patient described lifting heavy object and feeling a twang as their annulus tears

pain is worse on coughing

33
Q

where does acute disc tear typically effect

A

L4/5 or L5/S1

34
Q

how long does it usually take acute disc tear to settle

A

most by 3 months in the absence of complications

surgery musn’t be considered until after 3 months management

35
Q

bony nerve root entrapment

A

OA of the facet joints can result in osteophytes iminging on exiting nerve roots , resulting in nerve root symptoms and sciatica

36
Q

how is bony nerve root entrapment treated

A

surgical decompression, with trimming of the osteophyte may be performed in suitable candidates

37
Q

spinal stenosis

A

facet joint OA produces generalised narrowing of the lumbar spinal canal (cauda equina has less space) - spinal stenosis

multiple nerve roots can be compressed or irritated

38
Q

what can spinal stenosis lead to

A

neurogenic claudication - bilateral burning pain in legs on walking

39
Q

how does neurogenic claudication differ to vascular claudication

A

pedal pulses are present

claudication distance is inconsistent

pain is burning rather than cramping

pain is less walking uphill (spine flexes forward creating more space for cauda equina)

40
Q

cauda equina syndrome

A

the cauda equina is a bundle of nerves, and occasinally a very large central disc prolapse can compress all the nerve roots

results in a range of signs and symptoms collectively called cauda equina syndrome

lower motor neuron lesion

41
Q

how serious is cauda equina

A

surgical emergency - discectomy

prolonged compression can cause permanent nerve damage requiring colostomg and urinary diversion

urgent discectomy can prevent this

42
Q

main signs of cauda equina syndrome

A
  • incontinence/retention of faeces
  • reduced anal tone
  • saddle anaesthesia
  • bilateral leg pain
  • paralysis +/- sensory loss

in essence any patient with bilateral leg symptoms and any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven other wise

43
Q

management of cauda equina syndrome

A

PR examination is mandatory

urgent MRI to determine the level of prolapse

urgent discectomy

44
Q

red flag signs of back pain

A

cauda equina

back pain in the younger patients

new back pain in the older patients

nature of pain - severe, constant, worse at night

systemic upset

Immuncompromised

thoracic pain

previous carcinoma

structural spinal deformity

widespread neurological symptoms

45
Q

describe the pain from tumours

A

constant, unremitting, severe and worse at night (compare to mechanical back pain)

46
Q

why is new back pain in the older patient a red flag

A

higher risk of neoplasia, particualrly metastatic disease and multiple myeoma

47
Q

what benign tumours are common in adolescenets

A

osteoid osteoma

48
Q

what malignant primary bone tumour is common in adolescents

A

osteosarcoma

49
Q

yellow flags for back pain

A

Psychosocial factors that are indicative of long term chronicity and disability:

  • Low mood
  • High levels of pain/disability
  • Belief that activity is harmful, low education level
  • Obesity
  • Job dissatisfaction
  • Lot of lifting at work
  • Problem with claim/compensation (secondary gain)
50
Q

management of back pain

A

short term - NSAIDs and muscle relaxants

physio

osteopathy and chiropractic

referral

51
Q

osteoperotic crush fracture

A

with severe osteoperosis (bones less dense due to loss of bone material), spontaenous crush fractures of the vertebral body can occur leading to acute pain and kyphosis

minority of patients go on to have chronic pain due to altered spinal mechanisms

52
Q

treatment of osteoperotic crush fractures

A

usually conservative

balloon vertebroplasty for patients with chronic pain has good results but is yet to be fully approved

53
Q
A
54
Q

name 3 ways in which the cervical vertebra differ

A
  • Triangular vertebral foramen
  • Bifid spinous process
  • Transverse foramen
    • For vertebral artery
55
Q

what action do the atlanto occipital and axial joints allow

A

Atlanto-occipital joint does nodding action, and atlanto-axial joint allows head rotation.

56
Q

atlas anatomy

A

no vertebral body or spinous process

57
Q
A
  • note C1 has no spinous process
  • note dens
58
Q

what type of joints are the vertebral body joints

A

2y cartilaginous joints

59
Q

what type of joints are the facet joints

A

synovial

60
Q

why is lumbar rotation less than thoracic

A

more vertically orientated facet joints

61
Q

paraspinal muscles

A

located posterolaterally to the spinal column

RB Y2 MSK 03 - Spine and Paediatric Orthopaedics (9 decks)

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