Lumbar Spine Problems

Question 1

what is mechanical back pain

Answer 1

recurrent relapsing and remitting back pain with no neurological symptoms

Question 2

what age do patients tend to get mechanical back pain

Answer 2

20 and 60

Question 3

what are symptoms of mechanical back pain

Answer 3

worse on movement an relieved by rest

no red flags

Question 4

what are red flag symptoms

Answer 4

non-mechanical pain
systemic upset
major, new neurological deficit
saddle anaesthesia +/- bladder or bowel upset

Question 5

what causes mechanical back pain

Answer 5

obesity 
poor posture or lifting 
depression 
degenerative disc prolapse 
facet joint osteoarthritis 
spondylosis

Question 6

what is spondylosis

Answer 6

where intervertebral discs lose water with age resulting in less cushioning and increased pressure on facet joint
leads to secondary OA
looks like scotty dog on X ray

Question 7

how is mechanical back pain diagnosed

Answer 7

diagnosis of exclusion of nerve root problem or pathological process

Question 8

how is mechanical back pain treated

Answer 8

analgesia
physiotherapy
NO bed rest

Question 9

when only reason surgery be considered

Answer 9

if two adjacent vertebrae effected by oA

instability diagnosed by MRI

Question 10

what is an acute disc tear / discogenic back pain

Answer 10

an acute tear which occurs in outer annulus fibrosis of an intervertebral disc

Question 11

when does acute disc pain classically occur

Answer 11

after lifting heavy object (eg lawnmower)

Question 12

what is symptoms of acute disc tear

Answer 12

pain is characteristically worse on coughing since this increases disc pressure and the periphery of disc is richly innervated

Question 13

how is acute disc tear treated

Answer 13

analgesia and physiotherapy

symptoms usually resolve but take 2-3 months to settle

Question 14

what is sciatica

Answer 14

disc tear occurs in L4 - S3
gelatinous nucleus pulpous can herniate or prolapse through tear
disc material can impinge on nerve root resulting in altered dermatomal sensation and myotomal power

Question 15

what is general sciatica symptoms

Answer 15

radiating pain is felt as a neuralgic burning or severe tingling pain radiating down back of thigh to below the knee

Question 16

what happens in L3/4 prolapse sciatica

Answer 16

L4 root entrapment
pain down medial ankle
loss of quadriceps power
reduced knee jerk

Question 17

what happens in L4/5 prolapse sciatica

Answer 17

L5 root entrapment
pain down dorsum of foot
reduced power of extensor hallucis longus and tibialis anterior

Question 18

what happens in L5/S1 prolapse

Answer 18

S1 root entrapment
pain to sole of foot
reduced power plantar flexion
reduced ankle jerks

Question 19

how is sciatica diagnosed

Answer 19

positive sciatic stretch test

may have a cross over sign where sciatic stretch testing of the opposite side produces pain on affected side

Question 20

what is treatment of sciatica

Answer 20

analgesia
maintaining mobility
physiotherapy
(occasionally drug for neuropathic pain eg gabapentin used if leg pain severe)

Question 21

when would discectomy be indicated in sciatica

Answer 21

very occasionally
pain not resolving
localising signs suggesting specific nerve root involvement
positive MRI of nerve root compression
the surgery is for the LEG PAIN, not back pain

Question 22

what is bony nerve root entrapment

Answer 22

when OA of facet joints can results in osteophytes impinging on exiting nerve roots

Question 23

what symptoms does bony nerve root entrapment result in

Answer 23

nerve root symptoms and sciatica as previously mentioned

Question 24

what is treatment of bony nerve root entrapment

Answer 24

surgical decompression, with trimming of the impinging osteophytes, may be performed on suitable candidates

Question 25

what is spinal stenosis

Answer 25

with spondylosis and a combo of bulging discs, bulging ligament flavum and osteophytosis, the cauda equina of lumbar spine has less space - stenosis

Question 26

what is a result of this narrowing of space (spinal stenosis)

Answer 26

multiple nerve roots can be compromised / irritated

Question 27

what age to sufferers of spinal stenosis tend to be

Answer 27

over 60

Question 28

what are symptoms of spinal stenosis

Answer 28

claudication (pain in legs on walking)

Question 29

what is difference between the claudication in spinal stenosis and that of PVD

Answer 29

in spinal stenosis:

• claudication distance is inconsistent
• pain is burning (rather than cramping)
• pain is less walking uphill (spinal flexion creates more space for cauda equina)
• pedal pulses are preserved

Question 30

how is spinal stenosis treated

Answer 30

conservative = physio and weight loss

this fails and MRI evidence of stenosis = surgical decompression to increase space for cauda equina

Question 31

what is cauda equina syndrome

Answer 31

emergency whereby a very large disc prolapse compresses all nerve roots of cauda equine

Question 32

what are the main sacral roots that are effected in cauda equina

Answer 32

S4 and S5 controlling defaecation and urination

Question 33

what are symptoms of cauda equina syndrome

Answer 33

bilateral leg pain
parasthesiae or numbness
“saddle anaesthesia” - numbness around sitting area and perineum
altered urinary / bowel function (retention or incontinence)

Question 34

how is cauda equina diagnosed

Answer 34

PR exam mandatory!

urgent MRI required to determine level of prolapse

Question 35

how is cauda equina treated

Answer 35

surgical emergency - discectomy required once diagnosis confirmed

Question 36

what can be a complication of cauda equina

Answer 36

residual nerve injury with permanent bladder and bowel function
urgent surgery may prevent this
if it does happen = colostomy and urinary diversion

Question 37

back pain in younger patient (<20) is red flag, what can it suggest

Answer 37

osteomyelitis, discitis
spondylolisthesis (slipped vertebrae)
benign or malignant tumours
should probably refer or arrange MRI

Question 38

back pain in older patient (>60) is also a red flag, what can it suggest

Answer 38

arthritic change or crush factor

metastatic disease from breast, bronchus, prostate, thyroid or kidneys

Question 39

what does pain from a tumour tend to be

Answer 39

constant, unremitting, severe and worse at night

also have systemic upset

Question 40

if you have a red flag, what may you want to do

Answer 40

bloods
spine x ray (may show collapse or loss of a pedicle on AP view)
CXR
bone scan 
MRI scan

Question 41

what is an osteoporotic crush fracture

Answer 41

with severe osteoporosis, spontaneous crush fractures of vertebral body can occur

Question 42

what is symptom of osteoporotic crush fracture

Answer 42

acute pain and kyphosis (extreme curvature - hump)

Question 43

how is osteoporotic crush fracture diagnosed

Answer 43

plain xray

might want to consider MRI, bone scan or CT

Question 44

how is osteoporotic crush fracture treated

Answer 44

usually conservative (rest and pain meds) = get better in 3 months without specific treatment

Question 45

what have some clinicians tried in an attempt to treat chronic pain from osteoporotic crush fractures but the long term results not fully evaluated

Answer 45

balloon vertebroplasty (inserting balloon into vertebral body under fluoroscopic guidance, inflating balloon to lift corticies of vertebral body and injecting cement to fill void)