Lumbar Spine Flashcards
What is ‘mechanical back pain’
recurrent relapsing and remitting back pain that involves no neurological symptoms
presentation of mechanical back pain
worse on movement (mechanical) and relieved by rest
“red flag” symptoms in mechanical pain
There are none!!
age group that tends to be affected by mechanical back pain
20-60 years
causes of mechanical back pain
obesity lack of exercise poor lifting technique depression degenerative disc prolapse facet joint OA spondylosis
Tx of mechanical back pain
analgesia
physiotherapy
is bed rest advised for mechanical back pain
No!
leads to stiffness and spasm which exacerbates symptoms
do patients with mechanical back pain tend to have single level disease or multi level disease
multi level disease
what type of patient would be suitable for spinal stabilisation surgery for mechanical back pain
single level disease which hasn’t improved with physio and analgesia, and there is no claim/compensation involved
sections of an intervetebral disc
outer annulus fibrosis
inner nucleus pulposus
what is an acute disc tear
a tear of the outer annulus fibrosis of the IV disc
cause of an acute disc tear
typically after lifting a heavy object
why is an acute disc tear very painful
the periphery of the IV disc is richly innervated
presentation of an acute disc tear
history of heavy lifting
sudden onset
pain +++
pain worse on coughing
Tx acute disc tear
analgesia
physiotherapy
Ix for acute disc tear
Erect lumbar spine xray
When is an erect lumbar spine xray the preferred imaging modality
recent significant trauma
osteoporosis
age >70
When is lumbar MRI the preferred imaging modality
spinal malignancy infection fracture cauda equina syndrome ank spond or other inflammatory cause
What is sciatica
Clinical symptoms that result from compression of the L4, L5, S1 nerve roots. Compression is due to IV disc material that herniates through a tear in the IV disc and impinges on an exiting nerve root.
Causes pain and altered sensation in a dermatomal distribution and reduced power in a myotomal distribution
Symptoms of sciatica
radicular pain felt as neuralgic burning or tingling sensation, that radiates down the back of the thigh and below the knee
symptoms of an L3/L4 disc prolapse
L4 nerve root entrapment
pain down to the medial ankle (L4)
loss of quadriceps power
reduced knee jerk
symptoms of an L4/L5 disc prolapse
L5 root entrapment
pain down dorsum of foot
reduced power of Extensor Hallucis longus and tibialis anterior
symptoms of an L5/S1 disc prolapse
S1 root entrapment
pain to sole of foot
reduced power plantarflexion
reduced ankle jerks
Tx of disc prolapse/sciatica
analgesia and physiotherapy
Generally how long does an acute disc tear/prolapse/sciatic symptoms take to settle
70% settle in 3 months
90% settle in 18-24 months
What surgery is considered for disc prolapse and when is it considered
Discectomy
- pain is not resolving despite physio and there are localising signs suggesting a specific nerve root involvement and positive MRI evidence of nerve root compression
What causes bony nerve root entrapment in the lumbar spine
Bone growth (osteophytes) that occurs in OA. The osteophytes can impinge on exiting nerve roots and cause symptoms of sciatica
Tx of bony nerve root entrapment
Surgical decompression and trimming of osteophytes
what is spondylosis
loss of water content of IV discs with age
consequences of spondylosis
less cushioning
increased pressure on facet joints
secondary OA
what is spinal stenosis
narrowing of the spinal canal or neural foramina, producing nerve root compression, root ischaemia and a variable syndrome of back and leg pain
causes of spinal stenosis
several - anything disease process that can narrow the space
spondylosis
bulging discs
osteophytosis
how is spinal stenosis/claudication differentiated from vascular claudication due to PVD
the claudication distance is inconsistent
the pain is burning rather than cramping
pain is less walking uphill (spine flexion creates more space for the cauda equina)
pedal pulses are preserved
Mx of spinal stenosis
conservative Mx - weight loss, physio
what is cauda equina syndrome
a clinical syndrome resulting from a very large central disc prolapse, which compresses all the nerve roots of the cauda equina.
why is cauda equina syndrome a surgical emergency
affected nerve roots include the sacral roots S4/S5 which control defecation and urination.
prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion
clinical features of cauda equina syndrome
bilateral leg pain
“saddle anaesthesia” - perineal numbness
altered urinary function - urinary retention or incontinence
faecal incontinence and constipation
Ix for cauda equina syndrome
PR exam - mandatory
urgent MRI
Tx cauda equina syndrome
urgent discectomy
red flags of back pain
- back pain in young patient (<20 years)
- new back pain in older patient (>60 years)
- constant severe pain worse at night
- systemic upset
- history of cancer
in terms of lumbar spine, what is the risk for severe osteoporotic patients
osteoporotic crush # - basically the vertebrae cant be supported and all crush together
symptoms of osteoporotic crush #
acute pain
kyphosis
Mx of osteoporotic crush #
conservative Mx
