Mini symposium - spine Flashcards
What is the most common type of prolapse?
Postero-lateral disc prolapse
True or false: the interveterbal discs are avascular structures
True
Describe the structure of intervertebral discs
- Secondary cartilaginous joint
- Annulus fibrosus - Tough outer layer
- Nucleus pulposus - Gelatinous core
Which ligaments connect intervertebral discs with the vertebral bodies?
- Anterior longitudinal ligament
- Posterior longitudinal ligament
What is it about the annulus fibrosis structure that resists rotational movements and twisting i.e preventing disc protrusion?
The fibres of the annulus fibrosis run obliquely and alternately (at right angle) between layers

How does the normal ageing process affect the intervertebral discs?
- Decreased water content of discs over time
- Disc space narrowing
- Degenerative changes in the facet joints (OA) - aggravated by smoking and weight gain
What processes happen within the spinal canal as a result of degeneration?
- Tearing of annulus fibrosis and protrusion of the nucleus
- Nerve root compression by osteophytes
- Central spinal stenosis
- Abnormal movement - spondylolysis or spondylolisthesis
Nerve root pain
- Fairly common
- Limb pain is worse than back pain
- Referred to as radicular pain
- Most will settle, about 90% in 3 months settle without surgical intervention
- Physiotherapy can be helpful in both managing the pain and maintaining stability of the spine and muscle tone in the core muscles around the spine
- Strong analgesia - if severe radicular pain
- If patient has not improved after 12 weeks then they should be referred for imaging - MRI
What signs may a person show if they have a compressed or irritated nerve?
- Root tension signs - the most well known of these is the sciatic nerve stretch test. If the patient has a disc prolapse pressing on L5 or S1 nerve root – on lifting their leg they would develop increasing pain (+ve result)
- Root compression signs i.e lose reflexes or sensation
What are the different stages/names for disc problems?
- Bulge (generalised) – common, majority asymptomatic, relevance?
- Protrusion (annulus weakened but still intact)
- Extrusion (through annulus but in continuity)
- Sequestration (dessicated disc material free in canal)

In cervical disc prolapse which vertebrae are most commonly involved?
C5/C6
Thoracic disc prolapse
- Very rare - less than 1% of prolapses
- Most at T11/T12
- Central, posterolateral and lateral herniations
Lumbar disc prolapse
- Most common type of prolapses
- Majority are L4/5 (45%) followed by L5/S1 (40%) then L3/4 (10%)
- Most are posterolateral because the weakest point of the posterior longitudinal ligament is posterolaterally
- Central disc prolapse may give pain in both legs, or may be back pain only
Look
Need to know this
- EHL - extensor hallucis longus

Cauda equina syndrome
- Medical emergency!!
- Admission, urgent MRI, emergency operation within 48 hours of onset
- If not identified and treated rapidly the patient may be left with longterm disability
- Sacral nerve roots compression can result in permanent bladder and anal sphincter dysfunction and incontinence
What are some causes of cauda equina syndrome?
- Cental lumbar disc prolapse (commonest)
- Tumour
- Trauma (burst or Chance fracture) or spinal stenosis
- Infection i.e epidural abscess
- Iatrogrenic i.e spinal surgery or manipulation, spinal epidural injection
What is a Chance fracture?
Chance fracture is a type of vertebral fracture that results from excessive flexion of the spine.
Clinical features of Caude Equina syndrome
- Symptoms are located in the buttocks and the legs - varying dysaethesiae (numbness) and weakness
- Almost always bowel or bladder dysfunction (urinary retention +/- incontinence overflow)
- Loss of perianal sensation, loss of anal tone and reflex (remember that in women that have children these things may be reduced due to childbirth)
- High index of suspicion in spinal post-op with increasing leg pain and presence of urinary retention
Cervical and lumbar spondylosis
- Spondylosis is another word for oestoarthritis
- Very common in particular in the cervical and lumbar aspects of the spine
- Produces degenerative changes in the facet joints, discs, ligaments etc. The degenerative changes tend to cause osteophytes to form and calcifications of the ligaments - narrows space for nerves
- If severe, the whole cord (not just the nerve roots) can be compressed => myelopathy. More common in cervical spine as a lot of the lumbar spine is just roots.
- Would cause UMN signs in limbs - increased tone, brisk reflexes etc
Which ligament lies between laminae?
Ligamentum flavum
Which ligament attaches transverse processes together?
Intertransverse ligament
What is spinal claudication?
Neurogenic claudication is a term used to describe the leg pain and symptoms during walking which are associated with the condition of lumbar spinal stenosis.
It can sometimes be hard to distinguish between vascular claudication and spinal claudication. In spinal claudication…
- Symptoms are usually bilateral
- Sensory dysaesthesiae (numbness and tingling) - don’t tend to get this in vascular claudication
- Motor weakness i.e foot drop (complain of tripping)
- Takes several minutes for symptoms to ease
- Pain tends to be worse walking down hills because you are extending the spine and narrowing the spinal canal where as in flexion (walking up hill, cycling etc) the room for the cauda equina is increased.
What are the 3 seperate groups in spinal stenosis?
- Lateral recess stenosis - nerve emerging from the spine is compressed
- Central stenosis
- Foraminal stenosis
How to treat lateral recess stenosis?
- Non-operative - may settle on its own
- Nerve root injection of steroid to diminish pain - done under x-ray, localised
- Epidural injection - steroid into epidural space - flows round multiple nerve roots - more general treatment
- Surgery is indicated - if patient is fit and symptoms persists - decompressing the nerve root










