MSS Case 3: Lumbar spondylolisthesis

Question 1

Anatomy and Function of spine

Answer 1

See lecture

Question 2

Anatomy of Spinal cord, Cauda equina, Nerve roots

Answer 2

Spinal cord ends (Conus medullaris): T12 / L1
Cauda equina: L2
Lumbar puncture: L4/5

Question 3

Motor and sensory supply to lower limbs

Answer 3

See lecture

Question 4

Physiology of pain, somatic and autonomic reflexes

Answer 4

See lecture MSS32

Question 5

***Common cause of lower back pain

Answer 5

1. Mechanical
   - Lumbar strain
   - Degenerative disease e.g. IV disc, Osteoarthritis
   - Spondylolisthesis
   - Herniated disc
   - Spinal stenosis
   - Osteoporosis
   - Fractures
2. Non-mechanical
   - Infection e.g. Osteomyelitis
   - Inflammatory arthritis e.g. Ankylosing spondylitis (HLA-B27 associated)
   - Neoplasm e.g. Multiple myeloma, Metastatic carcinoma, Retroperitoneal tumour
3. Visceral disease
   - Pelvic inflammatory disease
   - Renal disease e.g. Pyelonephritis
   - Aortic aneurysm
   - GI disease e.g. Pancreatitis

Symptoms: ***Sciatica etc.

Question 6

***Causes of lower limb Claudication symptoms

Answer 6

1. ***Vascular (Check lower limb pulse):
   - Peripheral vascular disease (Atherosclerotic blockage)
   - Flexion of hip cut off femoral artery —> numbness in leg
2. ***Neurogenic
   - associated with weakness
   - resulted from position change
   —> Spinal extension —> ↓ spinal canal diameter —> worsen leg cramping
   —> Spinal flexion —> ↑ spinal canal diameter —> relieve symptoms

Question 7

History taking from patients with low back pain

Answer 7

SOCRATES

1. Site
   - directly over spine —> Fracture / Arthritis
   - paraspinal —> Muscle
   - lateral back —> Kidney / Pleuritic pain / Hip pain
   - unilateral flank —> Pyelonephritis
   - between scapula —> MI / Aortic aneurysm
2. Onset
3. Character
   - type e.g. Burning —> Neuropathic
   - persistent / intermittent
   - at rest / night / morning
4. Radiation
   - Limbs —> Radiculopathy
   - Buttock / Legs —> Sciatic nerve compression
5. Associated symptoms
   - **Sensory disturbance —> Radiculopathy / Spinal cord compression
   - **Motor disturbance —> Cord compression
   - Urinary retention —> Cauda equina syndrome
   - Urinary incontinence —> Cauda equina syndrome
   - Early morning stiffness —> RA / Ankylosing spondylitis
6. Time course
7. Exacerbating / Relieving factors
   - worsen after meal —> Duodenal ulcer
   - worsen after rest —> RA / Ankylosing spondylitis
   - worsen after activity —> OA / Fracture
   - relieved after activity —> RA / Ankylosing spondylitis
8. Severity

Other history:

1. Past medical history
2. Drug history
3. Family history
4. Social history

Question 8

***Physical examination of spine

Answer 8

1. Inspection
   - posture
   - kyphosis / scoliosis / lordosis
   - scars
   - muscle wasting
   - gait
2. Palpation
   - tenderness
   - muscle spasms
   - warm / swelling
   - crepitus
3. ROM
   - flexion / extension
   —> **Straight leg test —> Pain in lower back / thigh —> Sciatica
   —> **Femoral nerve stretch test (Mackiewicz sign) —> L2-4 Disc protrusion (but Negative in Lumbosacral protrusion)
   - lateral bending
   - rotation

Question 9

***Neurological examination of lower limbs

Answer 9

1. Inspection
2. Gait
   - Ataxic
   - Parkinsonian
   - High-stepping: Deep peroneal nerve injury —> Foot drop
   - Hemiparetic (Circumduction)
   - Gait test:
3. Tandem gait test (Heel to toe)
4. Heel walking test
5. Romberg’s test —> Proprioceptive deficit
6. Tone
7. Power
8. Reflex
   - Knee jerk (L3/4)
   - Ankle jerk (L5/S1)
   - Plantar reflex (S1)
9. Sensation
   - Light touch sensation —> **DC pathway
   - Pin-prick sensation (Crude touch) —> **Spinothalamic pathway
   - Vibration sensation
   - Proprioception
   - Coordination

Question 10

Investigations for patients with low back pain and leg pain

Answer 10

1. X-ray
   - disc space
   - alignment of spine
2. MRI / CT
3. Blood tests
4. Bone scan
5. Nerve studies (EMG)

Question 11

Principles of managing lumbar spinal stenosis

Answer 11

1. Physiotherapy
   - stretching
   - strengthening
   - braces / corsets
2. Pharmacological
   - NSAIDs
   - Opioids
3. Surgical
   - Laminectomy (for spinal stenosis without spondylolisthesis)
   - Spinal fusion (for spinal stenosis with spondylolisthesis)
   Aim:
   —> **Decompress spinal canal by removing hypertrophic facet joints / ligamentum flavum to relieve spinal claudication symptoms
   —> **Stabilise L4/5 spondylolisthesis (by doing L4/5 fusion) to relieve mechanical lower back pain

Question 12

Epidemiology of lumbar spondylosis and lumbar spinal stenosis

Answer 12

LO omitted

Question 13

Socioeconomic impact of lumbar spondylosis and lumbar spinal stenosis

Answer 13

Patient:
- YLD + DALY

Medical system:

• Direct cost
• Opportunity cost

Society:

• Lower labour productivity
• Economic burden

Question 14

Importance of effective communication and explanation of results, symptoms, prognosis, treatment plans to patient

Answer 14

LO omitted