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MSK- Spine and Upper Limb > Lumbar Spine > Flashcards

Lumbar Spine Flashcards

1
Q

Following a lumbar disc prolapse, patients who are suitable for surgery usually have it after what period of time?

A

26 weeks after the onset of pain

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2
Q

Should patients with chronic pain be considered for surgery?

A

No

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3
Q

Give the red flags for spinal pathology? (8)

A

Aged < 20 or > 60 with NEW back pain, non-mechanical, history of cancer, history of steroid use, systemic upset, structural deformity, signs of cauda equina, severe pain for 6+ weeks

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4
Q

Cauda equina syndrome is time sensitive. How soon does it need to be treated?

A

Within 48 hours

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5
Q

What can damage to the growth plate in adolescence cause?

A

Premature fusion and cessation of growth which can lead to kyphosis

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6
Q

What are chance fractures?

A

Highly unstable fractures

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7
Q

What happens if a spinal fracture occurs in ankylosing spondylitis?

A

This is a very dangerous and unstable injury which may be made worse with a collar. Always keep their neck in their natural position.

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8
Q

What test should always be done in a fracture in a patient with ankylosing spondylitis?

A

CT

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9
Q

What are the outcomes of spinal fractures in AS?

A

Poor outcomes, often don’t heal, can cause pseudotumours

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10
Q

Straight leg raise should be tested if you suspect what diagnosis?

A

Sciatica

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11
Q

What is the 1st line investigation for back pain if there are red flags present?

A

MRI

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12
Q

> 90% of cases of back pain are what?

A

Mechanical pain

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13
Q

What are some management options for mechanical back pain?

A

Explanation and reassurance, encourage to mobilise, analgesics, muscle relaxants, physiotherapy, osteopathy and chiropractor

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14
Q

What is the role of NSAIDs in the management of mechanical back pain?

A

Can be used short term

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15
Q

What % of cases of prolapsed discs will settle alone?

A

70-90%

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16
Q

When is a prolapsed disc an emergency?

A

Cauda equina syndrome

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17
Q

The long term results of a prolapsed disc are the same whether operated on or not. True or false?

A

True

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18
Q

Who is claudication as a result of spinal stenosis most likely to occur in?

A

Males aged 50+, associated with obesity

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19
Q

What activities will be possible in someone with claudication as a result of spinal stenosis?

A

Cycling, and going uphill when walking is easier than downhill

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20
Q

When will discogenic pain be worse?

A

By the end of the day, on moving and on flexion

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21
Q

Myelograms are rarely used now, what condition can they show?

A

Spinal stenosis

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22
Q

What are some symptoms of facet arthropathy?

A

Morning stiffness, pain which is worse with extension and at rest, better with activity and may radiate to the legs

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23
Q

Is imaging required for non-specific low back pain?

A

No

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24
Q

What are some behavioural (yellow flags) for back pain?

A

Low mood, high levels of pain/disability, belief that activity is harmful, obesity, litigation, job problems

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25
Q

When assessing back pain, as well as physical factors, what else should be included in the history?

A

Occupation, social factors and litigation

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26
Q

Why should you be suspicious of patients who know exactly when their back pain comes on?

A

Because back pain is usually insidious

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27
Q

Pain which is worse when is generally a concern?

A

At night

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28
Q

What movement will accentuate any structural spinal deformity?

A

Forward bending

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29
Q

Pain from sciatica will be in what pattern?

A

Dermatomal

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30
Q

If a patient is struggling to straight leg raise, what should you get them to do which is essentially exactly the same thing?

A

Sit up at 90 degrees with their legs straight infront

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31
Q

Should pushing downwards on a patients head (axial pressure) cause any back pain?

A

No

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32
Q

What is a downside of MRI for back pain?

A

It can give a lot of false positives

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33
Q

X-rays are usually pretty useless for spinal disease, what condition can they show?

A

Spinal stenosis

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34
Q

CT scans are good for showing what?

A

Inflammation

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35
Q

What can be done to manage severe back pain in the pain clinic?

A

Nerve block/ablation

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36
Q

What is a common presentation of disc prolapse?

A

Episodic back pain, leg pain and neurology (related to dermatomes and myotomes)

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37
Q

How many cases of disc prolapse will settle in the first 3 months? How many in 18-24 months?

A

3 months- 70%, 18-24 months- 90%

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38
Q

Patients with sciatica will generally have surgery if there is no improvement after how long?

A

3 months

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39
Q

What is the failure rate of surgery for back pain?

A

25%, with 3-5% coming out worse off

40
Q

What are some adverse indicators to surgery for back pain?

A

Litigation, benefit claims, chronic pain syndromes/behaviours

41
Q

There is increasing evidence of a link between back pain and what experiences?

A

Childhood abuse, PTSD, white coat stress

42
Q

What conditions can make back pain seem worse? What can often make it better in these cases?

A

Anxiety and depression, distraction can make it better

43
Q

The majority of cases of scoliosis are caused by what?

A

Idiopathic

44
Q

Early onset idiopathic scoliosis is defined as below what age?

A

7

45
Q

What is a common theme in scoliosis and spinal deformity?

A

Imbalance of the number of growth plates

46
Q

What are some conditions which scoliosis can be secondary to?

A

Neuromuscular conditions, tumours, spina bifida

47
Q

When are surgical treatments given for scoliosis and spinal deformity?

A

When conservative treatment has failed, adolescents with a > 50% slip, neurological deficit, postural deformity

48
Q

What is spondylolysis?

A

Defect or stress fracture of the vertebral arch

49
Q

What is spondylolisthesis?

A

Forward slippage of one vertebrae on another

50
Q

In osteoarthritis of the facet joints, which movement makes pain worse?

A

Extension of the spine

51
Q

If a specific joint is implicated in spinal OA, what treatment may help?

A

Facet joint injections

52
Q

OA in one or two segments can be treated with what? What is the disadvantage to this?

A

Fusion- will affect the adjacent level in around 5 years time

53
Q

Both mechanical back pain and sciatica can radiate to the thighs and buttock. How can you tell these apart?

A

Only pain from sciatica will go below the knee

54
Q

What is often the cause of mechanical back pain?

A

Awkward twisting or poor lifting technique leading to acute muscular or ligamentous strain or sprain

55
Q

What are some non-pathological factors that mechanical back pain may be related to?

A

Obesity, lack of physical activity, early OA

56
Q

Will there be neurological symptoms in mechanical back pain?

A

No

57
Q

When is mechanical back pain generally better and worse?

A

Better with rest, worse on movement

58
Q

What is spondylosis?

A

Essentially OA; intervertebral discs lose water content resulting in less cushioning and increased pressure on the facet joints

59
Q

Is bed rest advised in mechanical back pain? Why/why not?

A

No- this can lead to stiffness and spasm which may make it worse

60
Q

If there is single level OA or instability which has not improved with conservative management and there are no adverse indicators to surgery, what can be done very rarely?

A

Stabilisation surgery

61
Q

Is there a role for surgery in multiple-level OA or spinal instability?

A

No

62
Q

Effects of spinal stabilisation surgery will generally last how long?

A

5 years

63
Q

Where does an acute disc tear occur?

A

The outer annulus fibrosis of an intervertebral disc

64
Q

When does an acute disc tear typically occur?

A

After lifting a heavy object

65
Q

Why is an acute disc tear so painful?

A

The outside of the disc is highly innervated

66
Q

When is pain from an acute disc tear typically worse?

A

Coughing, as this increases pressure on the disc

67
Q

How long can it take for symptoms of an acute disc tear to settle?

A

3 months

68
Q

What are the mainstay of treatment for an acute disc tear?

A

Analgesia and physiotherapy

69
Q

What makes a lumbar radiculopathy or sciatica different from just a disc tear?

A

In these cases, the nucleus purposes herniates out through the tear which may impinge on the exiting nerve root

70
Q

What neurological symptoms may be present in a lumbar radiculopathy or sciatica?

A

Pain and altered sensation in a dermatomal pattern, reduced power in a myotomal pattern

71
Q

What may happen to reflexes in lumbar radiculopathy/sciatica?

A

Reduced

72
Q

What nerve roots contribute to the sciatic nerve and can cause sciatica?

A

L4, L5, S1

73
Q

The pain from sciatica can radiate to where, where mechanical back pain cannot?

A

Below the knee

74
Q

What are the first steps of management for lumbar radiculopathy or sciatica?

A

Analgesia, maintaining mobility, physiotherapy

75
Q

If the pain from lumbar radiculopathy/sciatica is extremely severe, what analgesia can be used?

A

Neuropathic painkiller e.g. gabapentin

76
Q

When may a discectomy be indicated for lumbar radiculopathy/sciatica?

A

Pain is not resolving, specific nerve root involvement, positive MRI of root compression

77
Q

What is bony nerve root entrapment?

A

OA of the facet joints can cause osteophytes to impinge on the exiting nerve roots

78
Q

In suitable candidates, what surgical management can be used for bony nerve root entrapment?

A

Surgical decompression or trimming of osteophytes

79
Q

What makes claudication from spinal stenosis different from PVD?

A

Claudication distance is inconsistent, pain is burning, less painful going uphill, pedal pulses are present

80
Q

What surgery may be used in spinal stenosis in suitable candidates?

A

Surgical decompression to give the caudal equina more space

81
Q

What happens in caudal equina syndrome?

A

A large central disc prolapse compresses the nerve roots of the caudal equina

82
Q

Why is caudal equina syndrome an emergency?

A

The affected nerve roots include the sacral roots (especially S4/S5) which control urination and defaecation

83
Q

What can prolonged compression in caudal equina syndrome cause?

A

Permanent nerve damage requiring colostomy and urinary diversion

84
Q

What surgery is needed urgently in cauda equina syndrome?

A

Urgent discectomy

85
Q

What are some symptoms of cause equina syndrome in terms of pain/neurology?

A

Bilateral leg pain, parasthesia or numbness and ‘saddle parasthaesia’- numbness around the sitting area and perineum

86
Q

What are some symptoms of caudal equina syndrome in terms of urination and defaecation?

A

Usually urinary retention but incontinence can also occur, faecal incontinence and constipation

87
Q

Which patient is caudal equina syndrome until proven otherwise?

A

Bilateral leg pain with suggestion of altered bladder or bowel function

88
Q

What examination is necessary in caudal equina syndrome?

A

PR exam

89
Q

What test is used to assess the level of the prolapse in cauda equina syndrome?

A

MRI

90
Q

Younger children are more susceptible to what?

A

Infection (osteomyelitis, discitis)

91
Q

Adolescents are at the peak age for what?

A

Spondylolisthesis or benign (osteoid osteoma) or malignant (osteosarcoma) tumours

92
Q

Patients aged 60+ are more at risk of what conditions?

A

OA, crush fractures, malignancy

93
Q

A malignancy in the spine in older patient is more likely to be what?

A

Metastases or multiple myeloma

94
Q

Constant, severe pain which is worse at night is more suggestive of what conditions?

A

Tumours or infection

95
Q

What are some investigations which should be done in an individual with back pain red flags?

A

Bloods, spinal x-ray, chest x-ray, bone scan, MRI

96
Q

What fractures can occur in severe spinal OA?

A

Spontaneous crush fractures of the vertebral body

97
Q

What can OA crush fractures lead to?

A

Acute pain and kyphosis, a minority go on to have chronic pain

MSK- Spine and Upper Limb (13 decks)

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