Lumbar Spine Pathology Flashcards
What percentage of patients with back pain have a recurrence within two years?
60-80%
What are the three types of low back pain?
Acute: < 6 weeks
Sub-acute: 6-12 weeks
Chronic: > 12 weeks
What are the 3 categories of low back pain?
- Simple musculoskeletal pain (95%)
- Spinal nerve root compression (4%)
- Serious spinal pathology (1%)
What do intervertebral discs consist of?
Nucleus pulposus
- Centre of disc
- 3D lattice of collagen fibres
- Gel-like structure, retains water
Annulus fibrosus
- Outer layer
- Fibrocartilage & elastin
Vertebral endplates
- Between disc & vertebral body
- Provides nutrition for the disc
When does intradiscal pressure increase?
With any activity that increase intra-abdominal pressure
What are the causes of discogenic pain?
- Fissures in annulus fibrosis (usually chronic)
- Bulge
- Herniating
- Extrusion of contents
- Impingement of spinal cord/nerve roots
How is the nucleus pulpous affected by degenerative disc disease?
Loss of volume, pressure and hydration from 25 years onward
How is the annulus fibrosis affected by degenerative disc disease?
Fissures, can result in herniation
How is the endplate affected by degenerative disc disease?
- Collapse/microfracture of endplate, becomes concave
- Reduced nutrition of nucleus pulpous as subchondral plate forms
- Schmorl’s nodes
What are Schmorl’s nodes?
When the disc herniates vertically through the endplate
What is facet joint OA often preceded by?
Degenerative disc disease
What is spondylolysis (pars interarticularis injury)?
Defect of pars interarticularis (runs between two articular processes of spine)
What are the different types of spondylolysis?
- Unilateral/bilateral
- Congenital
- Degenerative
- Traumatic
- Isthmic (stress #)
- Pathological (bone disease)
What is spondylolisthesis?
- Develops from spondylolysis
- Complete fracture of the pars interarticularis
- Vertebral body moves anteriorly due to lack of support
How is spondylolisthesis graded?
I: 1-25% slip
II: 26-50% slip
III: 51-75% slip
IV: 76-100% slip
What are the medical red flags of the lumbar spine?
- Cauda equine syndrome
- Ankylosing spondylitis
- Compression fractures
- Spinal canal stenosis
- Visceral afferents & referred pain
What is caudal equine syndrome?
- Compression of caudal equine (bundle like structure of nerves extending from L1/L2)
- Medical emergency
What are the symptoms of caudal equina syndrome?
- Saddle anaesthesia
- Bowel or bladder dysfunction (e.g. cannot pass urine)
- Bilateral leg weakness
What is ankylosing spondylitis?
- Bamboo appearance in spine
- Pain/stiffness in entire spine
- Usually between 20-30 years
- Spine starts to fuse, loss of curvature
- Pelvis is the first place to show any changes
What is ankylosing spondylitis commonly associated with?
- Inflammation in eyes
- Inflammatory bowel disease
What population are commonly affected by compression fractures?
Elderly with sudden, severe pain & low bone density
What is spinal canal stenosis?
Ischemia of lumbosacral nerve root secondary to compression (e.g. disc herniation, osteophytes, ligamentum flavum hypertrophy)
What are the symptoms of spinal canal stenosis?
- Presents with neurogenic claudication (leg pain/discomfort originating from a nerve)
- Unilateral/bilateral pain
- Numbness (non- dermatomal)
- Weakness (non-myotomal)
- Cramping in thighs/calves with prolonged standing/walking
- Eased by flexion
How does visceral pain present in the spine?
Perceived as being from an area of skin innervated by the same segmental level as the visceral afferent
What are the spinal causes of leg pain/neurological symptoms?
- Somatic referred pain
- Radicular pain
- Claudication
- Peripheral nerve injury
What is nociceptive back pain?
- Evoked by a noxious stimulus of structures within lumbar spine
- No leg pain or neurological symptoms
What is somatic referred pain?
- Noxious stimulus of LS structures produces referred pain into leg
- Pain is perceived in regions with same segmental innervation (cross-talk)
- No stimulation of nerve roots
- No neurological signs
What are the symptoms of somatic referred pain?
Leg pain, usually dull, aching, poorly localised
What is radicular pain?
- Pain evoked by ectopic discharges from dorsal root or ganglion
- Caused by anything that puts pressure on the nerve root (usually disc herniation)
What are the symptoms of radicular pain?
- Sharp, shooting, electric pain
- Usually well defined in a narrow band into the leg
What is a radiculopathy?
- Refers to neurological symptoms of radicular pain
- Nerve conduction problem along a spinal nerve/nerve root
- Presents with pins & needles, numbness (dermatomal), weakness (myotomal), reduced reflexes
What is an example of peripheral nerve sensitivity?
Piriformis syndrome
- Due to excessive tightness in piriformis or sitting on edge of hard chair
- May also have general sensitivity of nerve
