Mini Symposium: Spine Flashcards
What is the pathophysiology of intervertebral disc herniation?
1 - Annulus fibrosis is torn and the nucleus protrudes through posterior longitudinal ligament (PLL)
2- Nerve root becomes compressed by osteophytes
3 - Central spine becomes stenosed
4 - Disc herniation is usually postero-lateral
What are the common causes of lower back pain?
1 - Prolapsed disc
2 - Trauma
3 - Fractures
4 - Ankylosing Spondylitis
5 - Degenerative
6 - Osteoporotic vertebral prolapse
7 - Cauda Equina syndrome
What is the epidemiology of spinal cord injuries?
- 1000/year
- Male > Female
- Peak 20-29 years
What are the most common causes of spinal cord injury?
1 - Falls
2 - RTA’s
3 - Sport
What are the red-flag symptoms of lower back pain?
Age - <20 years or > 55 years
Acute onset in elderly people
Constant or progressive pain
Nocturnal Pain
Worse pain lying supine (face upwards)
Fever, night sweats, weight loss
History of malignancy
Bilateral or alternating leg pain
What is the pathology of intervertebral disc degeneration during the normal ageing processes?
1 - Decreased water content of discs
2 - Disc space narrowing
3 - Degenerative changes observed on x-rays
4 - Degenerastive changes in the facet joints
What are the clinical features of intervertebral disc herniation and sciatica?
- Limb pain > back pain
- Pain occurs in a nerve root distribution
- Root tension & compression signs
- Dermatomes & myotome involvement
What are the clinical features of cauda equina syndrome?
- Injury or precipitating event
- Location of symptoms: bilateral buttock + leg pain with weakness
- Bowel or bladder dysfunction (urinary retention +- incontinence overflow)
- PR exam: saddle anaesthesia, perianal loss of sensation, loss of anal tone
- High index of suspicion in spinal post-op patients
What are the classic symptoms that cauda equina patients complain of?
- Bilateral leg pain
- Numb bum
- Incontinence
How is cauda equina syndrome managed?
- MRI
- If MRI contraindicated, then lumbar CT myelogram
- Treatment = Operation within 48hrs
What are the 2 different types of lumbar disc prolapse?
1 - Lateral disc protrusion
2 - Central disc protrusion
What type of joints are found at intervertebral discs?
Secondary cartilaginous
What is the tough outer layer surrounding the intervertebral discs called?
Annulus Fibrosus
What is the name of the gelatinous core found in the centre of intervertebral discs?
Nucleus pulposus
Which part of the intervertebral disc most commonly tears in disc prolapse?
Annulus Fibrosus
What condition occurs as a result of the annulus fibrosus tearing and the intervertebral disc prolapsing?
Nerve/cord root compression
What ligaments attach the vertebral discs to the vertebral bodies?
Anterior longitudinal ligament
Posterior longitudinal ligament
In root/cord compression (due to disc prolapse) which ligament does the disc prolapse through?
Posterior longitudinal ligament
What is the nucleus pulposus mainly composed of?
Water (88%) is collagen & proteoglycans
In which direction do most disc prolapses mostly occur?
Postero-lateral
What is the normal ageing process associated with the intervertebral discs?
1 - Discs water content decreases
2 - As a result, the disc space narrows
What can speed up the normal ageing process of the intervertebral discs?
Smoking
What are the features of nerve root pain?
- Limb pain > Back pain
- Pain occuring in a nerve root distribution (radicular)
- Associated with dermatomes and myotomes
How is nerve root pain treated?
- Most cases of nerve root pain resolve on their own due to bodies own inflammatory cells helping
- Physiotherapy
- Strong analgesia
How long after onset of nerve root pain should a patient be referred for specialist treatment?
12 weeks
What imaging modality should be used to investigate nerve root pain?
MRI
What are the different classes of intervertebral disc problems?
Bulge - common and mostly asymptomatic
Protrusion - Annulus fibrosus weakened but still intact
Extrusion - Nucleus pulposus has burst through annulus fibrosus
Sequestration - Nucleus pulposus has broken up and disc material is free in the vertebral canal
At which vertebral level is cervical disc prolapse mostl likely to occur?
C5/6
At what vertebral levels are thoracic disc herniations most likely to occur?
T11/12
At what vertebral levels are LUMBAR disc herniations most likely to occur?
L4/5
What is the difference between lateral disc protrusions and central disc protrusions?
Central disc protrusion:
- Both nerve roots at vertebral level will be affected
- Both legs can be affected
What should be done once cauda equina syndrome has been diagnosed?
1 - Urgent MRI scan
2 - Emergency operation within 48h
Which nerve roots can become compressed in cauda equina syndrome?
Sacral nerve roots
What can be the outcome of cauda equina syndrome?
Permanent bladder and anal sphincter dysfunction and incontinence
What is cauda equina syndrome?
Sudden pressure or compression to the spinal cord at the level of the cauda equina
What is the most common cause of cauda equina syndrome?
Central lumbar disc prolapse
What questions should be asked when taking a history in a suspected case of cauda equina syndrome?
1 - Do you have normal sensation when passing urine?
2 - Do you have a feeling of bladder fullness
What are the most classic symptoms of cauda equina syndrome?
Bilateral leg pain
Numb bum
Incontinence
What is the 1st step to take after identifying cauda equina syndrome?
MRI scan
If MRI scan is contraindicated for cauda equina syndrome, what imaging modality should then be used?
CT myelogram
In cauda equina syndrome, how many patients did not fully recover normal urinary function?
30%
What is spondylosis of the cervical and lumbar spine?
The age-related wear and tear of the vertebral column
Degenerative change observed at the facet joints, discs and ligaments
Often known as spinal osteoarthritis
What is thought to be the cause of spondylosis of the cervical and lumbar spine?
- Dehydration of the vertebral discs occuring due to the normal ageing process
- Causes a reduction in height of the spinal column, meaning the facet joints become misaligned, leading to osteoarthritis and production of osteocytes
- The shrinking of the spine also causes the ligamentum flavum to buckle leading to spinal cord compression
If the cervical or lumbar spondylosis is severe enough, what condition can occur?
Myelopathy - compression of the whole spinal cord (not just roots as happens in less severe cases)
What category of symptoms occur when the entire spinal cord is being compressed?
UMN signs - increased tone, brisk reflexes
What movements occur at the facet joints in the lumbar spine?
Flexion
Extension
What are the ligaments of the vertebral column?
1 - Anterior longitudinal ligament
2 - Posterior longitudinal ligament
3 - Ligamentum flavum (between laminae)
4 - Interspinous & supraspinous ligaments (between spinous processes)
5 - Intertransverse ligament (between transverse processes)
What is spinal claudication?
Stenosis of the spine causing impingement or inflammation of the nerves emmenating from the spinal cord
What are the symptoms of spinal claudication?
- Bilateral pain
- Abnormal sensation
- Weakness (foot drop - resulting in tripping over)
- Pain may continue after stopping walking
- Pain worse walking downhill
What are the different types of spinal stenosis?
1 - Lateral recess stenosis
2 - Central stenosis
3 - Foraminal stenosis
How is lateral recess stenosis treated?
1 - Non-operative
2 - Nerve root injection
3 - Epidural injection
4 - Surgery
What is the cause of lateral recess stenosis?
Bony overgrowth of facet joints
Loss of vertebral disc height and subsequent disc bulging
What is the cause of central spinal stenosis?
Enlarged spinal ligaments
Bony overgrowth of the facet joints
What is foraminal stenosis?
Narrowing of the cervical disc space caused by enlargement of the uncinate process
What is spondylolisthesis?
Slipping of a vertebral body
What is the treatment for spondylolisthesis?
- Conservative with lifestyle changes
- Surgery for persistent pain
