Pathology in the Spine - Lumbar and Cervical Flashcards
Mechanical back pain is (better/worse) with movement and (relieved/exacerbated) by rest
Worse with movement
Relieved by rest
What are the two sections to an intervertebral disc?
In an acute disc tear, which section is damaged?
Classically, when is the pain from an acute disc tear exacerbated?
Annulus fibrosus (outer circular layer)
Nucleus pulposus (centre of the disc)
Annulus fibrosus is damaged in an acute disc tear, and classically the pain is made worse when coughing
How are acute disc tears managed?
Symptoms usually resolve themselves, but this can take 2-3 months
Analgesia and physiotherapy are the mainstays of treatment
What is sciatica also known as?
How is it brought about?
Lumbar radiculopathy
Disc herniation (e.g. as a result of a tear, causing the nucleus pulposus to expand out) results in nerve compression, causing numbness, tingling and pain
What is the mechanism of pathology behind bony nerve root entrapment?
Osteoarthritis of the facet joints in the vertebrae results in osteophytes impinging on the nerve roots
If a disc prolapse occurred at the level of L4/L5, which nerve is more at risk of compression if this prolapse was…
- paracentral
- lateral?
Paracentral prolapse = L5
Lateral prolapse = L4
If a disc prolapses at the L4/L5 level, the nerve roots most at risk are L4 and L5.
The L4 nerve root exits laterally below the pedicle of the L4 vertebra. Therefore, it is at risk from a lateral disc prolapse.
The L5 nerve root is travelling down the spinal column and is traversing the L4/L5 junction and therefore is at risk from a more central disc prolapse.
What are some of the red flag symptoms that indicate a possible cauda equina syndrome?
What investigation is mandatory if cauda equina syndrome is suspected?
Bilateral leg pain
Parasthaesia/numbness
Saddle anaesthesia
Altered urinary function/faecal incontinence
PR exam is mandatory
What are some of the general red flag symptoms associated with back pain?
Pain in young patients (<20 years)
New back pain in older patients (>60 years)
Pain that is constant/severe/worse at night
Features of systemic upset - fever, night sweats, fatigue, weight loss etc.
If a patient presented with an acutely painful back and rapid onset kyphosis, what might the diagnosis be?
How are these managed?
Osteoporotic crush fracture
Manage conservatively - give pain relief/physiotherapy
Balloon vertoplasty could also be used - involves inserting a balloon into the vertebrae and inflating to lift the cortices
What is the pathophysiology and presentation of cervical spondylosis?
Disc degeneration leads to accelerated osteoarthritis development of the facet joints
Presentation
- slow onset pain and stiffness in the neck which may radiate to the shoulders and occiput
- upper limb radiculopathy if nerve compression
Possible cause of neck pain if the pain presented…
- slowly over a prolonged period of time
- acutely
Slow progression - cervical spondylosis
Acute pain - cervical disc prolapse
In cervical disc prolapse, what level is the prolapse found most commonly?
Which nerve is most commonly compressed?
Prolapse normally at C6/C7, with C7 being more commonly compressed
(this would mean it was a paracentral herniation)
What conditions are associated with cervical spine instability?
Down’s Syndrome - atlanto-axial subluxation (C1/C2)
Rheumatoid arthritis - destruction of the synovial joint between the atlas and the dens of the axis can also result in atlanto-axial subluxation
What is the treatment for cervical spine instability?
Mild cases can be treated with a collar and warning against certain activities
If more severe/recurrent, may require surgical stabilisation/fusion of the vertebrae
