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Neurology > Mechanical Spinal Problems > Flashcards

Mechanical Spinal Problems Flashcards

1
Q

what are the causes of lower back problems?

A
  • Mechanical back pain.
  • Lumbar disc herniation.
  • Cauda equina.
  • Lumbar stenosis.
  • Malignancy.
  • Trauma.
  • Infection, e.g. tuberculosis.
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2
Q

what are the common causes of mechanical back pain?

A

obesity, lack of exercise, strain on paraspinal muscles, facet joint osteoarthritis

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3
Q

what are the clinical features of mechanical back pain?

A

morning stiffness which resolves with movement.

Pain is made worse by prolonged sitting or when rising from a seated position

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4
Q

what occurs with facet joint hypertrophy?

A

referred pain from the nerve supplying the facet joint that mimics sciatica; but does not radiate below the knee.

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5
Q

what are the red flag features of low back pain?

A
  • Age: >60 or <20 years old
  • Pain not improved by rest
  • Pain that wakes the patient up at night
  • Urinary retention/incontinence and faecal incontinence
  • Saddle anaesthesia
  • History of malignancy
  • Unexplained weight loss.
  • Night sweats, Fever, immunosuppression or IV drug abuse
  • Progressive neurological deficit
  • Trauma
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6
Q

what is the pathophysiology of a lumbar disc herniation?

A

occurs when the nucleus herniate through a tear in the annulus ring and compress adjacent nerve roots

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7
Q

which nerve roots are affected in lumbar disc herniation?

A

L4/5 level and L5/S1

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8
Q

what are the different directions of vertebral disc prolapse?

A

posterolateral/paramedian
far lateral/extraforaminal
central/medial

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9
Q

which nerve is affected in posterolateral herniated discs?

A

traversing nerve (the nerve root that exits below the level of prolapsed disc)

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10
Q

which nerve is affected in far lateral herniated discs?

A

exiting nerve (the nerve root that exits at the level of the prolapse)

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11
Q

what could central/medial herniated discs result in?

A

lumbar stenosis or cauda equine

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12
Q

what is the definition of radiculopathy?

A

dysfunction of a nerve root causing a dermatomal sensory deficit with weakness of the muscle groups supplied by that nerve

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13
Q

what is the definition of sciatica?

A

pain along the sciatic nerve usually due to compression of nerve roots L4 – S3)

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14
Q

what are the general features of lumbar disc herniation?

A

o Sciatic pain pattern
o Numbness or tingling sensations along the distribution of the affected nerve.
o Weakness.
o Straight leg raise test positive

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15
Q

what are features of sciatic pain?

A

Shooting pain radiating from the buttocks down to the posterior knee/leg. The pain can be exaggerated by coughing or sneezing.

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16
Q

what are the clinical features of a L5/S1 prolapsed intervertebral disc?

A

o Pain along the posterior thigh with radiation to the heel.
o Weakness of plantar flexion
o Sensory loss in the lateral foot.
o Reduced or absent ankle jerk.

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17
Q

what are the clinical features of a L4/L5 prolapsed intervertebral disc?

A

o Pain along the posterior/posterolateral thigh, radiating to dorsum of the foot and great toe.
o Weakness of dorsiflexion of the toe or foot.
o Paraesthesia and numbness of the dorsum of the foot and great toe.
o Reflex changes unlikely.

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18
Q

what are the clinical features of a L3/L4 prolapsed intervertebral disc?

A

o Pain in the anterior thigh.
o Wasting of the quadriceps muscle.
o Weakness of the quadriceps function and dorsiflexion of foot.
o Diminished sensation over anterior thigh, knee and medial aspect of lower leg.
o Reduced knee jerk.

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19
Q

what are the indications for surgery in lumbar disc prolapses?

A
  • Failure of conservative treatment - First line management
  • Pain
  • Central disc prolapse: Patients with bilateral sciatica or features indicating a central disc prolapse, such as sphincter disturbance and diminished perineal sensation, should be investigated promptly.
  • Tumour
  • Neurological deficits
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20
Q

what are the clinical features of spinal claudication?

A 
Usually intermittent
Worse on mobilising
Eases at rest + bending forwards
Pain often back of thighs/calves
Altered sensation
Heaviness/weakness
Spinal vs vascular claudication
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21
Q

how does cauda equina occur?

A

compression of the cauda equine of the spinal cord

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22
Q

what are the causes of cauda equina?

A
  • Prolapsed lumbar disc: usually a midline herniation commonly at L4/5
  • Tumour compression.
  • Trauma.
  • Infection
  • Hematoma.
23
Q

what are the clinical features of cauda equina?

A 
urinary retention
saddle paraesthesia
incontinence
low back pain
bilateral sciatic leg pain - radicular pain in both legs along with complete or partial loss of motor and sensory function
24
Q

what investigations should be done in cauda equina?

A

• MRI lumbosacral spine and a digital rectum examination

25
Q

cauda equina…

A

a neurosurgical emergency

26
Q

what is the management of cauda equina?

A

herniated disc –> discectomy
fracture –> decompression +- fixation
hematoma –> evacuation

27
Q

what is spinal stenosis?

A

narrowing of the spinal canal

28
Q

what part of the spinal cord is affected in lumbar spinal stenosis?

A

conus medullaris

L4/5, L3/4

29
Q

what are the causes of lumbar spinal stenosis?

A
  • hypertrophy of facets joints and ligamentum flavum
  • protruding intervertebral discs
  • spondylolisthesis
30
Q

what are the clinical features of lumbar spinal stenosis?

A

slow onset
Unilateral or bilateral hip, buttocks or lower extremity pain or burning sensation
Neurogenic intermittent claudication: leg weakness, tingling and numbness

31
Q

what are the precipitating and relieving factors of lumbar spinal stenosis?

A

precipitated by standing or back extension and relieved by sitting, lumbar flexion or walking uphill

32
Q

what is the distribution of pain in neurogenic claudication?

A

Dermatomal

33
Q

what is the distribution of pain in vascular claudication?

A

Sclerotomal (muscle group with same vascular supply)

34
Q

what are the exacerbating factors of neurogenic claudication?

A
  • Exercise: variable amount of exercise can elicit the pain (distance is inconsistent)
  • Prolonged standing at rest
35
Q

what are the exacerbating factors of vascular claudication?

A
  • Exercise: pain can be reproduced with a fixed amount of exercise or distance
  • Rare at rest
36
Q

what are the relieving factors of neurogenic claudication?

A
  • Resting: often slow (>30 mins)

* Posture: relieved on walking uphill, sitting, waist flexion

37
Q

what are the relieving factors of vascular claudication?

A
  • Resting: immediate relief

* Posture: not dependent on posture or position.

38
Q

what type of pain is in neurogenic claudication?

A

Burning

39
Q

what type of pain is in vascular claudication?

A

Cramping

40
Q

are there any changes to peripheral pulses in neurogenic claudication?

A

Normal

41
Q

are there any changes to peripheral pulses in vascular claudication?

A

Diminished or absent

42
Q

what are the causes of failed back syndrome?

A
  • Recurrence, residual compression
  • Nerve injury
  • Altered joint mobility
  • Instability
  • Fibrosis, arachnoiditis
  • Infection
  • Depression, anxiety
  • Diabetes
  • Smoking
  • BMI
43
Q

what is the management of failed back syndrome?

A
  • Difficult
  • Recurrence - ?re-operation
  • Infection - Antibiotics
  • Anti-inflammatories
  • Physiotherapy
  • Behavioural therapy
  • TENS
  • Antidepressants
  • Spinal cord stimulation
  • Intrathecal pump
44
Q

what is cervical spondylosis?

A

degenerative arthritic process involving the cervical spine and affecting the intervertebral disc and zygapophyseal joints

45
Q

how can cervical spondylosis present?

A

degenerative cervical myelopathy (UMN signs) or radiculopathy (LMN signs).

46
Q

what changes to the cervical discs occur in cervical spondylosis?

A

degeneration process causes stress on the articular cartilages of the vertebral end-plates.
Osteophytic spurs develop around the margins of the disintegrating end-plates.
These spurs can grow posteriorly into the spinal canal and anteriorly into the prevertebral space.

47
Q

what are the clinical features of cervical spondylosis?

A

radiculopathy
neck pain
myelopathy

48
Q

what are the radiological features of cervical spondylosis?

A
  • Narrowing of the disc space - C5/C6 and C6/C7

* Osteophyte formation

49
Q

what is the management of cervical spondylosis?

A

decompressive cervical laminectomy
anterior cervical discectomy
posterior cervical foraminotomy

50
Q

what is myelopathy?

A

spinal cord compression which causes UMN signs

51
Q

what are the clinical features of Degenerative Cervical myelopathy?

A
  • Imbalance and disturbance of gait which can lead to falls
  • “Numb, Clumsy hands” with difficulty holding a fork or buttoning shirt
  • Finger-tip paraesthesia
  • Urinary or faecal incontinence (rare).
  • Pain in a non-dermatomal distribution
  • Legs jump at night due to hyperreflexia
  • Weakness, hyperreflexia and spasticity, brisk reflexes in legs (upgoing plantars)
  • Positive Babinski and Hoffman’s signs.
  • Loss of dexterity using fingers – difficulty with fine motor tasks, dropping objects
52
Q

what is the gold standard investigation for Degenerative Cervical myelopathy?

A

MRI

53
Q

what are the MRI features of cervical myelopathy?

A

disc degeneration, ligament hypertrophy +/- spinal cord signal change

Neurology (18 decks)

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