Mechanical Spinal Problems Flashcards
what are the causes of lower back problems?
- Mechanical back pain.
- Lumbar disc herniation.
- Cauda equina.
- Lumbar stenosis.
- Malignancy.
- Trauma.
- Infection, e.g. tuberculosis.
what are the common causes of mechanical back pain?
obesity, lack of exercise, strain on paraspinal muscles, facet joint osteoarthritis
what are the clinical features of mechanical back pain?
morning stiffness which resolves with movement.
Pain is made worse by prolonged sitting or when rising from a seated position
what occurs with facet joint hypertrophy?
referred pain from the nerve supplying the facet joint that mimics sciatica; but does not radiate below the knee.
what are the red flag features of low back pain?
- 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
what is the pathophysiology of a lumbar disc herniation?
occurs when the nucleus herniate through a tear in the annulus ring and compress adjacent nerve roots
which nerve roots are affected in lumbar disc herniation?
L4/5 level and L5/S1
what are the different directions of vertebral disc prolapse?
posterolateral/paramedian
far lateral/extraforaminal
central/medial
which nerve is affected in posterolateral herniated discs?
traversing nerve (the nerve root that exits below the level of prolapsed disc)
which nerve is affected in far lateral herniated discs?
exiting nerve (the nerve root that exits at the level of the prolapse)
what could central/medial herniated discs result in?
lumbar stenosis or cauda equine
what is the definition of radiculopathy?
dysfunction of a nerve root causing a dermatomal sensory deficit with weakness of the muscle groups supplied by that nerve
what is the definition of sciatica?
pain along the sciatic nerve usually due to compression of nerve roots L4 – S3)
what are the general features of lumbar disc herniation?
o Sciatic pain pattern
o Numbness or tingling sensations along the distribution of the affected nerve.
o Weakness.
o Straight leg raise test positive
what are features of sciatic pain?
Shooting pain radiating from the buttocks down to the posterior knee/leg. The pain can be exaggerated by coughing or sneezing.
what are the clinical features of a L5/S1 prolapsed intervertebral disc?
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.
what are the clinical features of a L4/L5 prolapsed intervertebral disc?
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.
what are the clinical features of a L3/L4 prolapsed intervertebral disc?
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.
what are the indications for surgery in lumbar disc prolapses?
- 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
what are the clinical features of spinal claudication?
Usually intermittent Worse on mobilising Eases at rest + bending forwards Pain often back of thighs/calves Altered sensation Heaviness/weakness Spinal vs vascular claudication
how does cauda equina occur?
compression of the cauda equine of the spinal cord
what are the causes of cauda equina?
- Prolapsed lumbar disc: usually a midline herniation commonly at L4/5
- Tumour compression.
- Trauma.
- Infection
- Hematoma.
what are the clinical features of cauda equina?
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
what investigations should be done in cauda equina?
• MRI lumbosacral spine and a digital rectum examination
cauda equina…
a neurosurgical emergency
what is the management of cauda equina?
herniated disc –> discectomy
fracture –> decompression +- fixation
hematoma –> evacuation
what is spinal stenosis?
narrowing of the spinal canal
what part of the spinal cord is affected in lumbar spinal stenosis?
conus medullaris
L4/5, L3/4
what are the causes of lumbar spinal stenosis?
- hypertrophy of facets joints and ligamentum flavum
- protruding intervertebral discs
- spondylolisthesis
what are the clinical features of lumbar spinal stenosis?
slow onset
Unilateral or bilateral hip, buttocks or lower extremity pain or burning sensation
Neurogenic intermittent claudication: leg weakness, tingling and numbness
what are the precipitating and relieving factors of lumbar spinal stenosis?
precipitated by standing or back extension and relieved by sitting, lumbar flexion or walking uphill
what is the distribution of pain in neurogenic claudication?
Dermatomal
what is the distribution of pain in vascular claudication?
Sclerotomal (muscle group with same vascular supply)
what are the exacerbating factors of neurogenic claudication?
- Exercise: variable amount of exercise can elicit the pain (distance is inconsistent)
- Prolonged standing at rest
what are the exacerbating factors of vascular claudication?
- Exercise: pain can be reproduced with a fixed amount of exercise or distance
- Rare at rest
what are the relieving factors of neurogenic claudication?
- Resting: often slow (>30 mins)
* Posture: relieved on walking uphill, sitting, waist flexion
what are the relieving factors of vascular claudication?
- Resting: immediate relief
* Posture: not dependent on posture or position.
what type of pain is in neurogenic claudication?
Burning
what type of pain is in vascular claudication?
Cramping
are there any changes to peripheral pulses in neurogenic claudication?
Normal
are there any changes to peripheral pulses in vascular claudication?
Diminished or absent
what are the causes of failed back syndrome?
- Recurrence, residual compression
- Nerve injury
- Altered joint mobility
- Instability
- Fibrosis, arachnoiditis
- Infection
- Depression, anxiety
- Diabetes
- Smoking
- BMI
what is the management of failed back syndrome?
- Difficult
- Recurrence - ?re-operation
- Infection - Antibiotics
- Anti-inflammatories
- Physiotherapy
- Behavioural therapy
- TENS
- Antidepressants
- Spinal cord stimulation
- Intrathecal pump
what is cervical spondylosis?
degenerative arthritic process involving the cervical spine and affecting the intervertebral disc and zygapophyseal joints
how can cervical spondylosis present?
degenerative cervical myelopathy (UMN signs) or radiculopathy (LMN signs).
what changes to the cervical discs occur in cervical spondylosis?
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.
what are the clinical features of cervical spondylosis?
radiculopathy
neck pain
myelopathy
what are the radiological features of cervical spondylosis?
- Narrowing of the disc space - C5/C6 and C6/C7
* Osteophyte formation
what is the management of cervical spondylosis?
decompressive cervical laminectomy
anterior cervical discectomy
posterior cervical foraminotomy
what is myelopathy?
spinal cord compression which causes UMN signs
what are the clinical features of Degenerative Cervical myelopathy?
- 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
what is the gold standard investigation for Degenerative Cervical myelopathy?
MRI
what are the MRI features of cervical myelopathy?
disc degeneration, ligament hypertrophy +/- spinal cord signal change
