Session 2 - The lumbar spine and Associated Disorders Flashcards
Mechanical back pain
What is this characterised as?
Pain when the spine is loaded and this worsens with exercise and is relieved by rest
Mechanical back pain
How will the pain be described and what triggers it?
- Described as intermittent
- triggered by innocuous activity such as bad posture and exercise
Mechanical back pain
What are the risk factors?
- obesity
- poor posture
- a sedentary lifestyle
- incorrect manual handling techniques
- deconditioned core muscles
Degenerative changes in the vertebral column
What is disc degeneration?
When the nucleus pulposus of the intervertebral discs dehydrates with age leading to a loss of disc height, disc bulge and alteration of the load stresses on the joints.
Degenerative changes in the vertebral column
What is marginal osteophytosis?
Formation of osteophytes(bony spurs) called syndesmophytes adjacent to endplates of the discs.
Degenerative changes in the vertebral column
Why may osteoarthritic changes be seen?
Increased stress placed on facet joints due to the disc degeneration and marginal osteophytosis
Degenerative changes in the vertebral column
Why may facet joint osteoarthritis be perceived as painful?
The facet joints are innervated by the meningeal branch of the spinal nerve.
Degenerative changes in the vertebral column
Why may radicular or nerve pain occur?
Compression of spinal nerves due to the decrease in size of the intervertebral foramina because of the disc height decrease and arthritic changes in the facet joints and vertebral bodies.
Herniation of an intervertebral disc (slipped disc)
Why do patients feel pain with this?
Pain occurs due to herniated disc material pressing on a spinal nerve.
Herniation of an intervertebral disc (slipped disc)
What is the most common age group for this condition?
30-50 years
Herniation of an intervertebral disc (slipped disc)
Name the 4 stages of disc herniation
- Disc degeneration
- Prolapse
- Extrusion
- Sequestration
Herniation of an intervertebral disc (slipped disc)
Disc degeneration is one of the stages of disc herniation. What occurs in this stage?
Discs dehydrate and bulge due to chemical changes associated with ageing.
Herniation of an intervertebral disc (slipped disc)
Prolapse is one of the stages of disc herniation. What occurs in this stage?
The nucleus pulposus is usually contained within a rim of annulus fibrosus. Protrusion of the nucleus pulposus will occur with slight impingement into the spinal canal during this stage.
Herniation of an intervertebral disc (slipped disc)
Extrusion is one of the stages of disc herniation. What occurs in this stage?
The nucleus pulposus breaks through the annulus fibrosus but is still contained within the disc space.
Herniation of an intervertebral disc (slipped disc)
Sequestration is one of the stages of disc herniation. What occurs in this stage?
The nucleus pulposus separates from the main body of the disc and enters the spinal canal
Herniation of an intervertebral disc (slipped disc)
Name the 2 most common sites for ‘Slipped discs’
- L4/5 discs
- L5/S1 discs
- due to mechanical loading at these joints
Herniation of an intervertebral disc (slipped disc)
Name the 3 ways in which the nucleus pulposus can herniate
- paracentral prolapse
- far lateral prolapse
- central prolapse
Herniation of an intervertebral disc (slipped disc)
Out of the 3 ways the nucleus pulpous herniates, what is the most common way?
- Paracentral prolapse (posterolaterally - lateral to the posterior longitudinal ligament)
occurs in 96% of the cases
Herniation of an intervertebral disc (slipped disc)
What is the term ‘exiting nerve root’ replying to?
The nerve root that emerges from the spinal canal at the same level as the intervertebral disc
Herniation of an intervertebral disc (slipped disc)
What is the term ‘traversing nerve root’ replying to?
The nerve root that emerges at the level below the intervertebral disc
Herniation of an intervertebral disc (slipped disc)
Which nerve root is at risk in a far lateral herniation?
Exiting nerve root
Herniation of an intervertebral disc (slipped disc)
Which nerve root is at risk in a paracentral herniation?
Traversing nerve root
Herniation of an intervertebral disc (slipped disc)
Out of the 3 ways the intervertebral disc can prolapse, which way carries a risk of causing cauda equina syndrome?
Central herniation
Radicular leg pain (Sciatica)
What is Sciatica?
Sciatica is the name given to a pain caused by irritation or compression of one or more of the nerve roots that contribute to the sciatic nerve (L4-S3)
Radicular leg pain (Sciatica)
What are the causes of sciatica?
- marginal osteophytosis
- slipped disc
Radicular leg pain (Sciatica)
Why is the pain experienced described as following a path from ‘from the back to the dermatome’?
Typically experienced in the back and buttock and
radiates to the dermatome supplied by the affected nerve root.
Radicular leg pain (Sciatica)
Describe the typical distribution of pain with L4 sciatica?
- anterior thigh
- anterior knee
- medial leg
Radicular leg pain (Sciatica)
Describe the typical distribution of pain with L5 sciatica?
- lateral thigh
- lateral leg
- dorsum of foot
Radicular leg pain (Sciatica)
Describe the typical distribution of pain with S1 sciatica?
- posterior thigh
- posterior leg
- heel
- lateral border and sole of the foot
Radicular leg pain (Sciatica)
If paraesthesia occurred, where will this be felt?
In the affected dermatome rather than the full path from the lumbar spine to the dermatome
Cauda Equina Syndrome
What is the most common cause of this?
- Due to a central disc prolapse
- Canal filling disc compressing the lumbar and sacral nerve roots in the spinal canal
Cauda Equina Syndrome
What is the age group this occurs in the most?
30 - 50 years
Cauda Equina Syndrome
Name 3 other causes of this
- late-stage ankylosing spondylitis
- vertebral fracture
- spinal stenosis secondary to arthritis
Cauda Equina Syndrome
Name the red flag symptoms for this (BUPPE)
- Bilateral sciatica (L5)
- Urinary/faecal incontinence
- Painless retention of urine
- Perianal numbness (saddle anaesthesia)
- Erectile dysfunction
Cauda Equina Syndrome
How is this treated?
By surgical decompression within 48 hours of the onset of sphincter symptoms, otherwise, the prognosis is poor
Cauda Equina Syndrome
Give 3 consequences of missing this diagnosis?
- Chronic neuropathic pain
- loss of sensation and lower limb weakness requiring a wheelchair
- Impotence
Spinal Canal Stenosis
What is this?
An abnormal narrowing of the spinal canal that compresses either the spinal cord or the nerve roots.
Spinal Canal Stenosis
Often affect the elderly, what are some of the causes of this?
- Disc bulging
- Facet joint osteoarthritis
- Ligamentum flavum hypertrophy
- Spondylolisthesis
- Trauma
Spinal Canal Stenosis
What type of stenosis is most common?
Lumbar stenosis
Spinal Canal Stenosis
What are the symptoms? (depend on the region of the cord or nerve roots that are affected)
- Discomfort whilst standing (95% of patients)
- Discomfort or pain in the shoulder, arm or hand (for cervical stenosis) or in the lower limb (for lumbar stenosis)
- Bilateral symptoms in approximately 70% of patients
- Numbness at or below the level of the stenosis
- Weakness at or below the level of the stenosis
- Neurogenic claudication
Neurogenic claudication
What is this?
- a symptom rather than a diagnosis.
- pins and needles in the legs on prolonged standing and on walking, radiating in a sciatica distribution.
Neurogenic claudication
Explain the pathway in which this occurs
- compression of nerve roots
- venous engorgement of nerve roots during exercise
- reduced arterial inflow (ischaemia)
- pain and paraesthesia
Neurogenic claudication
How is pain relieved?
- rest
- flexion of the spine
Spondylolisthesis
What is this?
Anterior(forward) displacement of the vertebra above relative to the vertebra below.
Spondylolisthesis
What is it caused by?
Disconnection of the vertebral body from the vertebral arch
Spondylolisthesis
What is the treatment for this?
Surgical using screws and rods to stabilise the spine
Lumbar puncture (knee-chest position)
At which vertebral level is the needle inserted?
- L3/L4
- L4/L5
