PBL 21: Spinal disorders Flashcards
LO 1: Discuss the basic epidemiology, pathophysiology, presentation, investigation, management and prognosis of ankylosing spondylitis
What is ankylosing spondylitis?
a type of spondyloarthritis that leads to inflammation of the spine and other areas of the body
Epidemiology
Rare
More common in caucasian men
20-30 years old
Pathophysiology
Unknown - thought vertebral discs become inflamed where they attach to vertebral bodies
Presentation
Skeletal features
Gradual onset of lower back pain >3months
Early am stiffness in back >30mins
Night pain in 2nd half of night
Back pain that improves with exercise
Alternating buttock pain
Question-mark posture
Extra skeletal features (4As)
Acute uveitis - inflammation of the uvea => eye redness, pain and blurred vision
Aortic incompetence - aortic valve doesn’t function properly => blood flows in reverse into left ventricle
Apical lung fibrosis - damaged scarred lung tissue at apex
Amyloidosis - build up of amyloid protein (abnormal protein) => kidney failure, heart failure
Investigations into ankylosing spondylitis
Bloods - FBC (anaemia), elevated ESR, elevated CRP, RF negative
MRI - x-rays may be normal
Management of ankylosing spondylitis
NSAIDS
anti-TNF
Exercise
Physio
DMARDs are less useful unless chronic peripheral arthritis
Prognosis of ankylosing spondylitis
Varied - can improve or get progressively worse, may be disabling
LO 2: Discuss the presentation, initial investigation, key differential diagnosis & initial management of back pain
Presentation:
Stiffness
Muscle spasm
Problems with posture
Stabbing pain
Numbness
Parathesia
Initial investigation:
History- may just need to rest
Blood- CRP ESR, HBA1C
X-ray
MRI
DIfferential diagnosis:
Mechanical low back pain:
Osteoarthritis of the spine
Prolapsed intervertebral disc
Vertebral crush fracture
Spinal stenosis/spondylolisthesis
Malignancy
Spondylolysis and spondylolisthesis
Cauda equina
Infection:
Discitis
Vertebral osteomyelitis
Vascular insufficiency
Hip causes:
Osteoarthritis
Avascular necrosis
Initial management:
Rest
Education
Manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage)
Psychological therapies using a cognitive behavioural approach with exercise, with or without manual therapy
NSAID
Weak opioids
Red flags:
Malignancy
Corticosteroids
Pt systemically unwell
Wt loss
Widespread neurology
Age < 20yrs or >55yrs
Violent trauma
Constant, progressive, non - mechanical back pain
Thoracic pain
IV drug abuse / HIV infection
Persisting severe restriction of lumbar flexion
Structural deformity
LO 3: Discuss the basic epidemiology, pathophysiology, presentation, investigation, management and prognosis of radiculopathies
What is a radiculopathy?:
Compression of a nerve root
Also known as a sciatica
Epidemiology:
Disc degeneration starts in the 3rd decade of life
Up to 3% of men and 1% of women will suffer sciatica related to a prolapsed intervertebral disc
What are the risk factors for radiculopathies?
Aging
Being overweight
Poor posture
Bad lifting techniques
Repetitive motions
Family history of degenerative bone conditions
Pathophysiology:
Stenosis - abnormal narrowing of a passage in the body
Osteophytes - bony projections along bone edges
Disc herniation - the nucleus pulposus bulges or ruptures the annulus fibrosus, causing pressure on the spinal nerves
Trauma - lumbar disc herniation is usually caused by lifting heavy objects while the spine is flexed
Injury to the lumbar spine results in loss of normal lumbar lordosis.
Causes spasm of the paraspinal muscles.
Presentation:
Cervical Radiculopathies
Pain in neck that radiates in the distribution of the affected nerve root
Neck is held rigidly and neck movements exacerbate pain
Paraesthesia and sensory loss
Lower motor neuron signs - weakness, wasting and reflex impairment
C5 Root Compression:
Muscle Weakness = Bicep, Deltoid, Spinati
Reflex Loss = Biceps
C6 Root Compression:
Muscle Weakness = Brachioradialis
Reflex Loss = Supinator
C7 Root Compression
Muscle Weakness = Triceps, Fingers, Wrist Extensors
Reflex Loss = Triceps
Lumbar Radiculopathies
Onset may be sudden or gradual
Or repeated episodes of lower back pain may precede sciatica by months or years
Constant aching pain felt in the lumbar region
Pain is exacerbated by coughing or straining. Relieved by lying flat.
Pain may radiate to the buttock, thigh, calf and foot
L4 Root Compression
Sensory Loss = Anterior Thigh
Muscle Weakness = Knee Extension
Reflex Loss = Knee
Positive Femoral Stretch Test
L5 Root Compression
Sensory Loss = Dorsum of Foot
Muscle Weakness = Ankle dorsiflexion, ankle inversion, hip flexion, foot drop, big toe dorsiflexion
Reflex Loss = None
Positive Sciatic Nerve Stretch Test
S1 Root Compression
Sensory Loss = Posterolateral aspect of leg and lateral aspect of foot
Muscle Weakness = Plantar Flexion
Reflex Loss = Ankle Reflex
Positive Sciatic Nerve Stretch Test
Investigation:
Where there is no trauma, imaging should not be carried out for isolated cervical pain
MRI - most common investigation
X-ray - offer limited benefit except for finding destructive lesions
EMG (Electromyography) + NCS (Nerve Conduction Studies) - helpful in evaluating severity of nerve damage and determining location of nerve root compression
Management:
Analgesics - Non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids
Physiotherapy - early mobilisation as bed rest does not help recovery. Back strengthening exercises and avoiding physical manoeuvres
Injections of local anaesthetic and glucocorticoids may help if symptoms are due to ligament injury or joint dysfunction
Surgery - disc decompression or discectomy
Prognosis:
90% of patients with sciatica recover following conservative treatment within 3 months
Majority of patients will improve by 4 weeks
LO 4: Discuss the basic epidemiology, presentation, investigation, management and prognosis of cauda equina
Cauda equina syndrome is a surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed. It requires emergency decompression surgery to prevent permanent neurological dysfunction.
Epidemiology
Cauda equina syndrome isn’t more likely to happen in a certain type of person, it just depends on what causes the compression.
Pathophysiology
The cauda equina is a collection of nerve roots that travel through the spinal after the spinal cord terminates around L2/L3.
The nerve roots exit either side of the spinal column at their vertebral level (L3,L4,L5,S1,S2,S3,S4,S5 and Co (coccygeal nerves))
Nerves the cauda equina supplies
Sensation to the lower limbs, perineum, bladder and rectum
Motor innervation to the lower limbs and the anal and urethral sphincters
Parasympathetic innervation of the bladder and rectum
Causes of cauda equina compression:
Herniated disc (most common cause)
Tumours, particularly metastasis
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Abscess (infection)
Trauma
Red flag presentation
Saddle anaesthesia (loss of sensation in the perineum - around genitals and anus)
Loss of sensation in bladder and rectum (not knowing they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the leg
Reduced anal tone (inability to squeeze the anal sphincter against a gloved finger)
Management
It is a neurosurgical emergency. It requires:
Immediate hospital admission
Emergency MRI scan to confirm or exclude cauda equina
Neurosurgical input to consider lumbar decompression
Prognosis
The sooner surgery is performed the better the chance of regaining function
Even with early surgery there is still chance patients can be left with bladder, bowel or sexual dysfunction
Leg weakness and sensory impairment can also persist
LO 5: Mechanisms of Referred pain
What is referred pain?
Referred pain is pain that is felt somewhere different from the origin eg, having pain in buttock from a herniated disc
Pain is transferred as nociceptive information to the brain where it travels to the somatosensory cortex.
The somatosensory cortex is responsible for processing touch, proprioception (knowing where your body is) and pain.
The body is comprised of dermatomes, which are areas of skin that a specific nerve root supplies sensation to. Every dermatome is named after the vertebrae from which the nerve root arises.
When a specific nerve root is compressed due to some various pathology, it will send a nociceptive signal to the brain, which is felt as radiculopathic pain, felt across the dermatome + myotome etc.
Dorsal horn convergence theory
This is one of the main explanations for referred pain (I am struggling to understand this so this is simplified), all nociceptive inputs converge at the same second order neurone in the spinal cord, so if you get a nociceptive signal from an organ your brain cannot interpret the difference between that signal and a signal coming from a specific dermatome, and because your brain can’t tell the difference it assumes the pain is coming from the dermatome, causing referred pain.
Radicular pain is specifically when a nerve is being irritated or compressed causing symptoms of pain and weakness paraesthesia etc.
Other referred pain only usually causes symptoms of pain in the dermatome.
LO 6: Describe the therapeutic interventions which are available to treat spinal pain
Basically back pain management
Education
teach to self-manage their low back pain with or without sciatica
emphasise the fact that exercise is helpful rather than damaging
Regular analgesia and/or NSAIDs
to improve mobility and facilitate exercise
Consider weak opioids
Bed rest is not helpful and may increase the risk of chronic disability
Referral for physical therapy
if pt hasn’t returned to normal activities in 6 weeks
e.g. spinal manipulation, mobilisation or soft tissue techniques such as massage
Psychological therapies
Low-dose tricyclic antidepressant drugs
help pain, sleep and mood
Cognitive behavioural approach with exercise
NICE approved interventions
Radio frequency
nerve root injections
Spinal fusion
LO 7: Discuss iatrogenic analgesia addiction- how it occurs and how it can be managed
Iatrogenic addiction is where a patient becomes addicted to a substance due to treatment
Tolerance and dependence are key.
Addiction starts as a pleasure but turns to something you feel you can’t live without.
Tolerance:
You can become tolerant to an opioid fairly quickly, therefore, to ensure adequate analgesia is still accomplished, rotation of opioids is used. This means that the dose doesn’t have to be ramped up to achieve the same level of pain relief.
Dependence:
Withdrawal from the substance causes physiological effects.
These can occur after being on opioids for a few days.
THESE ARE NOT TO BE CONFUSED WITH ADDICTION
In addiction, physical dependence is more pronounced, and psychological dependence and cravings are the main driving force.
Prescription drugs most commonly causing addiction: Opioids, anti-anxiety medication, sedatives and stimulants.
Addiction can occur due to physicians over prescribing, not tapering doses, leaving people on medication for too long, not noticing early signs of addiction etc.
Opioids are usually safe for a few days usage.
Signs and symptoms of prescription drug abuse
Opioids
Constipation
Nausea
Feeling high
Slowed breathing rate
Drowsiness
Confusion
Poor coordination
Increased dose needed for pain relief
Worsening or increased sensitivity to pain with higher doses
Other signs
Forging, stealing or selling prescriptions
Taking higher doses than prescribed
Being hostile or having mood swings
Sleeping less or more
Making poor decisions
Being unusually energetic, high or revved up
Being drowsy
Requesting early refills or continually “losing” prescriptions, so more prescriptions must be written
Trying to get prescriptions from more than one prescriber
How to manage it:
Psychotherapeutic strategies and didactic teaching (one person does the teaching) of alternative pain relief methods are often useful. The use of methadone for brief or more extended periods is sometimes helpful as an adjunct to psychotherapy.
LO 8: Discuss the structure and functional features of the lumbar intervertebral disc in health and disease
The lumbar intervertebral disc is a structure located between the vertebrae in the lower back, specifically between the L1 and L5 vertebrae. It consists of two main parts: the annulus fibrosus and the nucleus pulposus. The annulus fibrosus is the outer ring of the disc, made up of concentric layers of fibrous tissue, while the nucleus pulposus is the inner, gel-like portion of the disc.
In a healthy disc, the nucleus pulposus acts as a shock absorber, distributing forces evenly throughout the disc and providing flexibility to the spine. The annulus fibrosus is responsible for maintaining the disc’s shape and preventing the nucleus pulposus from protruding beyond the disc’s borders. The disc is also supplied by blood vessels that provide nutrients and oxygen to the cells within the disc.
In disease, the lumbar intervertebral disc can undergo degeneration, which can result in pain and loss of function. Disc degeneration can be caused by a variety of factors, including aging, genetics, and repetitive stress. As the disc degenerates, the nucleus pulposus can lose its water content, becoming less effective at absorbing shocks and increasing the likelihood of disc herniation. The annulus fibrosus can also become weakened, allowing the nucleus pulposus to protrude beyond the disc’s borders, causing pressure on nearby nerves and resulting in pain.
Treatment for lumbar intervertebral disc disease can vary depending on the severity of the condition. In mild cases, conservative treatments such as physical therapy, anti-inflammatory medication, and rest may be sufficient. More severe cases may require surgery, such as a discectomy or spinal fusion, to alleviate symptoms and prevent further damage. Additionally, preventative measures such as maintaining good posture, exercising regularly, and avoiding repetitive stress can help reduce the risk of lumbar intervertebral disc disease.
LO 9: Describe the gross anatomy of the spinal cord and the structure and function of a typical spinal nerve
Anatomy of the spine
Five sections of the spine:
Cervical: C7 vertebral bodies
C1 and C2 nerve roots go above C1 and C2 vertebrae bodies
C3 -C8 nerve roots are below
Thoracic: T12 vertebral bodies
Lumbar: L5 vertebral bodies
Spinal cord ends at L1 in most people (sometimes down to L3 in minority of people)
Becomes cauda equina nerves
Sacral: S5 vertebral bodies
Note: Spinal cord ends at L1 and forms cauda equina nerves.
Diagram of vertebral column
Pedicle —> where screws can be attached into spine in surgery
Facets —> The inferior facet articulates with the superior facet surface of the vertebral body below it
Diagram of motion segment
Annulus fibrosus —> tough exterior of intervertebral disc
Nucleus pulposus —> soft inner core of the intervertebral disc
Meningeal Layers
Cerebral spinal fluid (CSF) —> found in subarachnoid space
CSF is sampled below L3 as spinal cord end here in most people
Role of meninges: to protect and support spinal cord
Muscles of the spine:
Erector spinae muscles
Extend and laterally flex spine
Spinalis
Longissimis
Iliocostalis
Transversospinalis muscles
Rotate spine
Semispinalis
Rotatores
Multifindus
Stabilise spine:
Intertransversarii
Interspinales
Ligaments of the spine:
Prevents hyperextension and hyperflexion of spine, keeps the vertebrae aligned:
Anterior longitudinal ligament
Posterior longitudinal ligament
Ligamentum Flavum
Interspinal ligament
Supraspinous ligament
Limits hyper flexion of cervical spine and head
Nuchal ligament
Structure and Function of a Typical Spinal Nerve
In the spinal cord there are 31 bilateral spinal nerves – each pair belonging to a cord segment
Spinal nerves start as two linear series of nerve fascicles (bundle of axons) which are attached to the dorsolateral and ventrolateral aspects of a cord
Groups of 6-8 fascicles, that are attached to each cord segment, merge to form dorsal and ventral roots
Dorsal and ventral roots then go to their corresponding intervertebral foramen where they join to form spinal nerves
Spinal nerves are mixed nerves – containing both afferent + efferent neurons
Dorsal roots contain primary afferent neurons – these run from peripheral sensory receptors to the spinal cord + brain stem
Nerve cell bodies of these neurons are in the dorsal root ganglia
Ventral roots contain efferent neurons – cell bodies located in spinal grey matter
o Made up of motor neurons which innervate skeletal muscles + preganglionic neurons of the autonomic nervous system
C1-C7 spinal nerves exit from vertebral canal above the first seven cervical vertebrae
C8 spinal nerve exits below seventh vertebra
Remaining spinal nerves leave below their corresponding vertebral bodies
Only in cervical region do the spinal cord segments lie adjacent to their corresponding vertebral bodies due to different lengths of the spinal cord and vertebral canal
After spinal nerves leave the intervertebral foramina, they divide to produce a thin dorsal ramus and larger ventral ramus
Dorsal ramus = supplies muscles + skin of back region
Ventral ramus = supplies muscles + skin of front of body + limbs
