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Sem 2 - MSK > Lumbar Spine > Flashcards

Lumbar Spine Flashcards

1
Q

What are the most mobile parts of the brain?

A

Cervical and Lumbar spine - This is where most problem are.

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2
Q

What are the functions of the vertebral column?

A

Central bony pillar of the body

Supports the skull, the pelvis, per limbs and thoracic cage.

Protection of the spinal cord and the cauda equina

Movement - highly flexible structure of bones, intervertebral discs and ligaments.

Haemopoiesis - red marrow (Produce red cells)

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3
Q

What is the structure of the lumbar vertebra?

A

General characteristics:

  • Kidney shaped vertebral body
  • Vertebral arch posteriorly with gives rise to 7 processes
  • Vertebral foramen which contains conus, cauda equina and meninges
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4
Q

What are the 7 processes in the vertebral arch?

A
  • 1 x spinous process
  • 2 x transverse processes (left and right)
  • 2x superior articular processes (facets) interlock with the vertebra above
  • 2x inferior articular processes interlock with the vertebra below
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5
Q

What type of bone is the lumbar vertebra made from? Why?

A

10% cortical bone 90% cancellous bone.

This is because it is the weight baring bit part of the body.

Also, More room in body for other activities and it makes the spine lighter.

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6
Q

What are the surfaces of the end plates covered in and how are they linked to adaject vertebral bodies?

A

Superior and Inferior Articular surfaces covered with hyaline cartilage. Linked to adjacent

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7
Q

How are the vertebral bodies linked to one another?

A

They are linked to adjacent vertebral bodies by intervertebral discs.

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8
Q

Why are there bigger vertebrae at bottom?

A

Because there are greater compressive forces distally so thee vertebral bodies have a larger surface area to cope with this.

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9
Q

What is the role of the lamina?

A

Bridge of bone that connect the transverse process to the spinous process.

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10
Q

What is the role of the pedicle?

A

Connects transverse process to body.

The bigger the intervertebral foramen, the longer and larger the pedicle.

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11
Q

When superior and inferior articular process join, they form a…

A

Facet joint.

  • They are lined with hyaline cartilage.
  • Paired
  • Spinal nerves emerge through intervertebral foramina.
  • Orientated in a Sagittal plane - more gliding.
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12
Q

Why is the interlocking design of a facet joint a good thing?

A

Prevent anterior displacement of vertebra

Orientation determines the amoun of flexion and rotation permittted.

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13
Q

What types of joint do we have in the spine?

A

Fibrous joints, non Mobile (ligaments) eg Sacroiliac joint

Cartilaginous joints - partially mobile eg Intervertebral disc

Synovial joints eg Facet joint (Hip, Knee, Shoulder, Elbow).

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14
Q

What is the composition of the intervertebral disc?

A
  • These account for 25% of the legth of the vertebral column.
  • 70% water, 20% collagen, 10% Proteoglycans
  • Slightly wedge shapes
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15
Q

Why do people get shorter as they age?

A

This is because the proteoglycans which keep water in the centre of the disc loose thier ability to attatct water. This means that they get shorter.

Also, as you age, you develop compression fractures which further shorten the spine.

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16
Q

What are the two regions of the intervertebral disc?

A
  • Nucleus pulposus (central)
  • Annulus fibrosus (peripheral)
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17
Q

What is the annulus fibrosus?

A
  • This is the peripheral part of the intervertebral disc
  • It has a highly complex design
  • Made from lamellae of annular bands in varying orientations
  • Type 1 collagen
  • Avascular and Aneural - They are the largest avascular structures in the body.They get nutrients from diffusion from the end plates.
  • Is the major ‘Shock absorber’
  • Highly resilient under compression - stronger than the vertebral body.
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18
Q

What is the nucleus pulposus?

A
  • This is the central part of the intervertebral disc.
  • It is a remnant of the notochord
  • Gelatinous, type 2 collagen
  • Disk height changes throughout the day
  • Surrounded entirely by annulus fibrosus
  • Centrally located in infants but more posteriorly located in adults.
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19
Q

What are the main ligaments aound the spine?

A
  • Anterior longitudinal ligament and posterior longitudinal ligament.
  • They both provide stability but anterior is stronger than posterior.
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20
Q

What is the anterior longitudinal ligament?

A
  • Anterior tubercle of atlas to scarum.
  • It blends with the periosteum of vertebral bodies.
  • Mobile over intervertebral discs
  • Prevents hyperextension.
  • Stronger than posterior longitudinal ligament
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21
Q

What is the posterior longitudinal ligament?

A
  • Body of axis to sacral canal
  • Continues superior to axis as ‘tectorial membrane’
  • Weaker than anterior longitudinal ligament
  • Prevents hyperflexion
  • Reinforces annulus centrally leading to paracentral disc prolapse.
22
Q

What is the ligamentum flavum?

A
  • Yellow in colour: Elastin elastic fibres
  • Between laminae of adjacent vertebae
  • Stretched during flexion of the spine.
23
Q

What are Interspinous liganements?

A
  • Relatively weak sheets of fibrous tissue
  • Unite spinous processes along adjacent borders
  • Well developd only in the lumbar region (stability in flexion)
  • Fuse with suprasinous ligaments.
24
Q

What are supraspinous ligaments?

A
  • Tips of adjacent spinous processes.
  • Strong bands of white fibrous tissue
  • Lax in extention
  • Tight in flexion (mechanical support for vertebral column
25
Q

Where is the force on your spine during compression?

During Tension?

A

Compression: Anterior

Tension: Posterior

26
Q

How does force distribution on your spine change as you get older?

A

Normal : 80% of the weight is on the vertebral bodies and 20% of it is on the facet joints/

At 70: only 65 % of the weight it on the vertebral body and 35% on the facet joints.

This is because, as you get older, disc dehydration occurs which forces more of the force through the facet joints.

27
Q

What are the two types of curvature of the spine?

A

Lordosis = backwards

kyphosis = cures forwards

28
Q

What shape is the vertebral column in the foetus?

A

Flexed in a single curvature.

C-shaped

Concave anteriorly = kyphosis

This is known as the primary curvature and is retained throughout life in the thoracic, sacral and coccygeal regions.

29
Q

How does the spine develop from foetus to young adult?

A
  • The primary curvature is remodelled to add two secondary curvatures.
  • The cervical spine develops the first posterior concavity (cervical lordosis) when the young child begins to lift its head.
  • The lumbar spine loses its primary kyphosis during crawling.
  • When the child begins to standup and walk, lumbar lordosis develops.
  • Lumbar lordosis is the secondary curvature.
30
Q

Why is it good that the spine is curved?

A

It gives the spine more resilience and elasticity

31
Q

What is the vertebral column like in young adults?

A

Four distinct curvatures

2 kyphoses (anterior flexions) thoracic an sacrococcygeal - these are a continuation of the primary curvature of the foetus

2 lordoses (posterior flexions) lumbar and cervical - there are secondary (developmental) curvatures.

32
Q

How does the vertebral column change in old age?

A
  • Secondary curvatures start to disapear.
  • Loss of disc and osteoporotic fractures.
  • Continuous primary curvature is re-established leading to ‘senile kyphosis’
33
Q

In what physiological state does curvature of the spine occur?

A

The lumbar lordosis is exaggerated during pregnancy to ensure the head is above pelvis and strand up more easily

34
Q

How is the centre of gravity projected?

A

The weight of the body is projected into lower limbs about a line that passes centrally through the natural curvatures of the vertebral column.

Sacral vertebae: Fused, widened and concave anteriorly to transmit weight of the body through pelvis to legs.

35
Q

Where does the centre of gravity pass through?

A

The centre of gravity passes through the vertebral column at:

  • C1 and C2
  • C7 and T1
  • T12 and L1
  • L5 and S1

These are ‘weak points’ in the vertebral column where pathologies tend to develop

The curves need to be balanced to aid walking and stop us falling.

36
Q

What modalities are there of looking at the spine?

A
  • X-Ray
  • CT Scan - to look at bones
  • MRI scan - facets
  • Bone scan
37
Q

How common is mechanical lower back pain?

A

50% of the UK population will have reported lower back pain for at least 24 hours in a year, at least half these episodes will have lasted over 4 weeks.

Most people have back pain! 80% of the population will have back pain in their life.

38
Q

What are the causes of back pain?

A

Postural (slouching) - This causes your discs to change shape

39
Q

What is mechanical back pain?

A

Pain when the spine is loaded (sitting, standing not lying)

It is worse with exercise and relieved by stress.

It is intermittent and often triggered by innocuous activity (eg tying a shoelace)

You have a predisposition to LBP if: overweight, unhealthy lifestyle, deconditioned core muscles.

40
Q

How can you apply the bio-psyco-social model to lower back pain?

A

View the whole person to see what contributes the most.

As well as physical health, have to see what affect is has on their metal health:

  • Benefits
  • Accident
  • Fear / Beliefs
  • Job
  • Relationship

If a person takes sich leave for 6 months for chronic back pain then only 50% of these will retun to work.

If a person takes sick leave for a year then only 5% will return to work.

41
Q

What are age related spinous changes?

A
  • The nucleus pulposus dehydrates with age.
  • Loss of disk height - disk bulge.
  • Loaded stresses in the intervertebral disc alter - reactive ‘marginal osteophytosis’ adjacent to affected endplates - syndesmorphytes
  • Increased load stress on the facet joints - facet joint arthritis (This is innervated by meningeal branch of the spinal nerve)
  • Decreased size of intervertebral and vertebral foramen and compression of cauda equina or exiting spinal nerve roots.
42
Q

What are the four stages of a prolapsed intervertebral disc?

A

Degeneration: The chemical changes associated with ageing cause the disc to dehydrate and bulge

Prolapse: protrusion of the nucleus pulposus with slight impingement into the spinal canal. The nucleus pulposus is still contained within a rim of annulus fibrosus.

Extrusion: Nucleus pulposus breaks through annulus fibrosus but remians within the disc space.

Sequestration: Nucleus pulposus breaks through annulus fibrosus and separates from the main body of the disc in the spinal canal.

43
Q

Where do prolapses most commonly occur?

A

Moat commonly occurs at L4/5 or L5/S1

90% occur paracentrally

Usually herniate posterolaterally causing compression of spinal nerve roots

They usually occur in 30-50yr olds and 90% of them are resolved by 3 months.

44
Q

What is Sciatica?

A

Sciatica is compression of the nerve roots which contribute to the sciatic nerve.

45
Q

Which nerve roots contribute to the sciatic nerve?

A
  • L4
  • L5
  • S1
  • S2
  • S3
46
Q

What are the different types of sciatica?

A

The areas affected are based on the dermatomes.

  • L4 - Anterior thigh, Anterior knee, medial shin
  • L5 - Lateral thigh, lateral calf, dorsum of foot
  • S1 - posterior thigh, posterior calf, heel, sole of foot

You can work out where the prolapse is from how sciatica goes down leg.

47
Q

What is cauda equina syndrome?

A

Canal filing disc compressing the Lumbar and Sacral Nerve roots.

Occur in 30 - 50 year olds.

Sympoms include:

  • bilateral sciatica (both legs)
  • Perianal numbnesss (around bum)
  • Painless Retention of Urine
  • Urinary / faecal incontience.
  • Erectile dysfunction

It must be treated with surgical decompression within 48hrs of sphincter symptoms or the patient may experience:

  • Intermitted self catherisation
  • DRE (digital rectal exam)
  • Sexual Dysfunction
  • Many other symptoms - if severe then could be in a wheelchair.
48
Q

What is claudication?

A

People who gets pains or pins and needles in their legs when they walk or stand for prolonged periods of time. The pain radiates in a sciatica distribution.

It is caused by nerve compression or circulation in legs and it relived by rest, a change in position or flexion of the waist.

49
Q

What is spondylolisthesis?

A

A slip of the one vertebra on the other due to an abnormality of vertebral arch

50
Q

What are the types of spondylolistheis?

A

Dysplastic - a congenital abnormality of the facet joints.

Isthmis - a defect in the pars interarticularis

Degenerative - results from facet joint arthritis and remodelling

Iatrogenic - surgery induced when too much lamina and facet joint ahve been removed.

Pathological - tumour that affects the neural arch.

51
Q

What is a lumbar puncture?

A

It is the withdrawal of fluid from the subarachnoid space of the lumbar cistern.

It is an important diagnostic test for a variety of central nervous system disorders including meningitis and multiple sclerosis

52
Q

How do you conduct a lumbar pucture?

A
  • The patient lies on their side and in a ball to separate the vertebrae.
  • The skin covering the lower lumbar vertebrae is anaesthatised
  • A lumbar puncture needle is inserted in the midline between the spinous processes of the L3 and L4 (or L4 and L5) vertebrae.
  • After passing 4–6 cm in adults (more in obese persons), the needle “pops” through the ligamentum flavum, then punctures the dura and arachnoid, and enters the lumbar cistern. When the stylet is removed, CSF escapes and can be collected.

Sem 2 - MSK (22 decks)

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