Mini Symposium: Spine Flashcards
What are some anatomical feature of an intervertebral disc?
- Secondary cartilaginous joint
- Largest avascular structure in the body
- Tough outer layer - annulus fibrosus
- Gelatinous core - nucleus pulposus
Which ligaments connect the discs with vertebral bodies?
The anterior and posterior longitudinal ligaments
How do the fibres of the annulus fibrosis run?
Obliquely and alternately between layers
How does ageing affect the intervertebral discs?
- Decreased water content
- Disc space narrowing
- Degenerative changes on x-rays
- Degenerative changes in facet joints
What are the features of nerve root pain?
- Fairly common
- Limb pain worse than back pain
- Pain in a nerve root distribution
- Root tension signs
- Root compression signs
- Dermatomes and myotomes
What is the outcome of nerve root pain?
- Most will settle, about 90% in 3 months
- Physiotherapy
- Strong analgesia
- Referral after 12 weeks
- Imaging - MRI
What are the 4 ways an intervertebral disc can prolapse?
- Bulge - common, majority asymptomatic
- Protrusion - annulus weakened but still intact, elongated nucleus
- Extrusion - annulus ruptured, nucleus has herniated through
- Sequestration - desiccated disc material free in canal
In which vertebrae do cervical disc prolapses most commonly occur?
•C5/6
How common are lumbar, cervical and thoracic prolapses?
•lumbar>cervical>thoracic
Where are thoracic disc prolapses most likely to occur?
- T8-12
* Particularly T11/12
In which directions do thoracic prolapses occur?
- Central
- Posterolateral
- Lateral
Where do lumbar disc prolapses occur?
- Usually L4/5 (45%)
- L5/S1 (40%)
- L3/4 (10%)
In which directions do lumbar prolapses occur?
- Most are posterolateral - PLL weakness
* Central disc may give pain in both legs or may be back pain only
What is cause equina syndrome?
Compression of cauda equina
How is cauda equina approached?
- Surgical emergency
- MRI
- Operation with 48hr - delay results in permanent dysfunction
What can be the outcome of cauda equina?
•Sacral nerve roots compressed – can result in permanent bladder and anal sphincter dysfunction and incontinence
What is the aetiology of cauda equina syndrome?
- Central lumbar disc prolapse (commonest)
- Tumours
- Trauma (burst or Chance #, disc) or spinal stenosis
- Infection (epidural abscess)
- Iatrogenic (spinal surgery or manipulation, spinal epidural injection)
What are the clinical features of cauda equina syndrome?
- Injury or precipitating event
- Location of symptoms - bilat buttock & leg pain + varying dysaethesiae + weakness – beware
- Bowel or bladder dysfunction - urinary retention +/- incontinence overflow, bowel presentation unlikely
- PR exam - saddle anaesthesia (perianal loss of sensation), loss of anal tone & anal reflex
- High index of suspicion in spinal post-op patients with increasing leg pain in presence of urinary retention, bi-lateral leg pain
What imaging is used for CES?
- MRI
* If MRI not possible, lumbar CT myelogram
What imaging is used for CES?
- MRI
* If MRI not possible, lumbar CT myelogram
What treatment for CES?
•Always operative
What are the outcome of CES?
- 30% undergoing discectomy for cauda equina syndrome did NOT regain normal urinary function
- 25% with motor deficits never regained full power
- 33% with sensory deficits never regained normal sensation
- 25% with perianal paraesthesiae did not return to normal
- 26% had persitent sexual dysfunction
What is cervical and lumbar spondylosis (OA)?
Degenerative change at: •Facet joints •Discs •Ligaments etc. COMMON
What can happen insecure spondylosis?
- Whole cord can be compressed - not just nerve roots
* This causes myelopathy - UMN signs in limbs (increased tone, brisk reflexes)
What are the ligaments of the lumbar spine? (5)
- Anterior Longitudinal Ligament (ALL) – along the front of the vertebral bodies – broad, strong
- Posterior Longitudinal Ligament (PLL) – along the backs of the vertebral bodies, i.e. front of the spinal canal; narrower
- Ligamentum Flavum - between laminae
- Interspinous and Supraspinous Ligaments - between spinous processes
- Intertransverse Ligament - between transverse processes
What are the x-ray features of lumbar spondylosis?
•OA of facet and disc joints (+ degradation of ligaments)
What is spinal claudication?
Pain in lower limbs due to compression of cauda equina
How can spinal claudication be distinguished from vascular claudication?
- Usually bilateral
- Sensory dysaesthesiae
- Motor weakness - foot drop (tripping)
- Takes several minutes to ease after walking
- Worse walking downhill as the spinal canal becomes smaller in extension
Name some causes of spinal stenosis
- Osteoarthritis - breakdown of cartilage, bone spurs
- Herniated discs
- Thickened ligaments
What are the 3 groups of spinal stenosis?
- Lateral recess stenosis
- Central stenosis - usually bilateral
- Foraminal stenosis
What is the treatment for lateral recess stenosis?
- Patients have radicular symptoms
- Non-operative
- Nevre root injection - steroid
- Epidural injection (steroid) - useful for bilateral symptoms as not specific
- Surgery
How is central stenosis treated?
- Canal shape important - trefoil canal can increase risk, congenital, ageing creates more of a trefoil shape
- Non-operative
- Epidural steroid injection
- Surgery - 80% improve
How is foraminal stenosis treated?
- Non-Operative
- Nerve root injection
- Epidural injection
- Surgery
What is spondylolithesis?
When a vertebra slips out of position
What is spondylolysis?
- Defect in pars interarticularis
* Posterior and anterior elements separated (fracture)
What are the symptoms of spondylolisthesis?
Vary with type
How is spondylolisthesis treated?
- Depends on symptoms
- Conservative with lifestyle changes
- Surgery for persistent pain +/- nerve root entrapment
