Lumbar Spine (Session 2)

Question 1

What is Mechanical Back Pain?

Answer 1

Pain when Spine is loaded

Worsens with exercise

Relieved by rest

Question 2

How common is mechanical back pain?

Answer 2

Extremely -50% of UK Population reported lumbar back pain for at least 24 hrs in one year. 80% of Population will experience pain lasting more that 24 hrs

Question 3

What are the risk factors for mechanical back pain?

Answer 3

Obesity, poor posture, sedentary lifestyle, weak core muscles, incorrect manual handling techniques

Question 4

What is marginal osteoporosis?

Answer 4

Syndesmophytes (bony spurs) develop-adjacent to end plate of disc due to nucleus pulposus of intervertebral disc dehydrating with age- decreases height of disc. Increased stress on facet joints.

Question 5

What causes radicular nerve pain?

Answer 5

Compression of spinal nerves (intervertebral foramina shrink)

Question 6

Which Population are most affected by herniation of an intervertebral disc (‘slipped disc’)?

Answer 6

= common. 30-50years- 90% cases resolved in 3 months.

Question 7

What are the 4 stages of disc herniation?

Answer 7

1. Disc degeneration- dehydrate and bulge- chemical changes due to age
2. Prolapse- nucleus pulposus protrudes
3. Extrusion- nucleus pulposus- breaks through annulus fibrosis
4. Sequestration- nucleus pulposus enters disc canal

Question 8

What are the most common sites for a slipped disc?

Answer 8

L4/5 L5/S1

Question 9

At which sites are the nerve roots most vulnerable to herniation?

Answer 9

1-where they cross intervertebral disc (paracentrally) 2- where they exit spinal canal in neural foramen (laterally)

Question 10

In which direction does the nucleus pulposus usually herniate? 96% cases

Answer 10

Posterolaterally (paracentral prolapse)

Question 11

Apart from posterolateral- where else might the nucleus pulposus herniate?

Answer 11

Far lateral (2% cases) Central (2% cases) (ie toward spinal chord)

Question 12

What does a central herniation of the nucleus pulposus carry a risk of (developing)?

Answer 12

Cauda equina syndrome

Question 13

Which nerve root is most at risk with a ‘far lateral disc herniation’?

Answer 13

Exiting nerve root- nerve root that emerges at same level as intervertebral disc

Question 14

Which nerve root is most at risk with a ‘paracentral herniation’?

Answer 14

Transversing nerve root- nerve root that emerges at the level below.

Question 15

What is Sciatica?

Answer 15

Radicular leg pain

Pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.

Question 16

What causes sciatica?

Answer 16

Irritation of one or more nerve roots contributing to sciatic nerve:

e. g.
- Osteophytosis (bone spurs- form around damaged joints)
- Slipped disc

Question 17

What are the causes of cauda equina syndrome?

Answer 17

1- Disc prolapse (5% cases)

2-Tumours

3-Spinal infection/abscess

4-Spinal stenosis secondary to arthritis

5- Vertebral fracture

6- Spinal haemorrhage

7-Late stage ankylosing spondylitis

(ankylosis= stiffening and immobility of joint due to fusion of bones)

Question 18

What are the red flag symptoms for Cauda Equina Syndrome?

Answer 18

1-Bilateral sciatica 2-Perianal numbness 3-Painless retention of urine 4- Urinary/faecal incontinence 5-Erectile dysfunction

Question 19

How is Cauda Equina treated?

Answer 19

Surgical decompression within 48hrs- onset of sphincter symptoms. IF NOT prognosis = poor

Question 20

What happens if Cauda Equina syndrome is not diagnosed quickly?

Answer 20

Chronic neuropathic pain

Impotence

Faecal incontinence

Lower limb weakness

Having to perform self catheterisation

Question 21

What is Spinal chord stenosis?

Answer 21

Abnormal narrowing of spinal canal-compressing spinal cord/nerve roots

Question 22

What age group does spinal chord stenosis usually affect?

Answer 22

Elderly

Question 23

What are the potential causes of spinal chord stenosis?

Answer 23

• Disc bulging
• Facet joint osteoarthritis
• Ligamentum flavum hypertrophy
• Compression fractures of vertebral bodies
• Spondylolisthesis
• Trauma

Question 24

What are the symptoms of spinal chord stenosis?

Answer 24

• Discomfort standing
• Discomfort in shoulder/arm/hand/lower limb
• Bilateral symptoms in approximately 70% patients
• Numbness/weakness below level of stenosis
• Neurogenic claudication (claudication= cramping)

Question 25

What is the prognosis of a lumbar canal stenosis?

Answer 25

70% symptoms=unchanged 15% symptoms= get worse 15% symptoms= get better

Question 26

What is neurogenic claudication?

Answer 26

Symptom (not diagnosis) Patient reports pain/pins and needles in legs when prolonged standing and walking- radiating in sciatica distribution - patient tends to limp

Question 27

What causes neurogenic claudication?

Answer 27

Compression of spinal nerves–> venous engorgement during exercise–> reduced arterial flow–> transient arterial ischaemia - results in pain

Question 28

What may relieve neurogenic claudication?

Answer 28

Rest, change in position/ flexion of spine e.g. climbing stairs

Question 29

What is Spondylolisthesis?

Answer 29

Anterior displacement of vertebra above on the vertebra below. (had various underlying causes e.g. traumatic/pathological)

Question 30

What is a ‘Lumbar puncture’?

Answer 30

Withdrawal of fluid from subarachnoid space of lumbar cistern (cistern= subaracnoid space).

Question 31

How is a lumbar puncture carried out?

Answer 31

Skin anesthetized

Lumbar puncture needle in midline between L3 and L4 or L4 and L5 vertebrae

Located by finding plane transecting highest point of iliac crests

Needle ‘pops’ through ligamentum flavum- then dura and arachnoid. Enters lumbar cistern

CSF escapes- collected