Session 5 Clinical Conditions Flashcards
What is mechanical back pain characterised by
Pain when spine is loaded, that worsens with exercise and is relieved by rest . Intermittent.
Risk factors for mechanical back pain
Obesity, poor posture, Sedentary lifestyle, deconditioning of core muscles, poor seating and incorrect manual handling
2 main degenerative changes in vertebral column
Disc degeneration and marginal osteophytosis
Disc degeneration key points
- Nucleus pulposus of intervertebral discs dehydrates with age
- Decrease in height of discs, bulging and alteration of load stresses
- Osteophytes (bone spurs) called Syndesmophytes develop adjacent to end plate
What is marginal osteophytosis
Syndesmophytes developing adjacent to end plates of discs. Increased stress can cause osteoarthritis changes.
What are facet joints innervated by
Meningeal branch of spinal nerve, so arthritis in these joints is painful
As disc height decreases and arthritis develops in facet joints and vertebral bodies (due to disc generation and marginal osteophytosis), what happens
Intervertebral foramina decrease in size lading to compression of spinal nerves and radicular/nerve pain
Why does pain occur in herniated disc
Herniated disc material presses on spinal nerve
4 stages of disc herniation
- Disc degeneration
- Prolapse
- Extrusion
- Sequestration
What is disc degeneration
chemical changes associated with ageing cause discs to dehydrate and bulge
What is prolapse
Protrusion of nucleus pulposus occurs with slight impingement into the spinal canal
What is extrusion
Nucleus pulposus breaks through annulus fibrosis but is still contained within disc space
What is sequestration
Nucleus pulposus separates from main body of disc and enters spinal canal
Most common sites for slipped disc
L4/5 and L5/S1 due to mechanical loading
Nerve roots are most vulnerable at 2 sites:
- Where they cross the intervertebral disc
2. Where the exit the spinal canal in the intervertebral foramen
Nucleus pulposus most commonly herniates…
Posterolaterally (causing compression of a spinal nerve root within intertertebral foramen). Paracentral prolapse.
2% are far lateral and 2% are central
Nerve roots at risk in far lateral, paracentral and central herniation
Far lateral- exiting nerve root
Paracentral- transversing nerve root
Central- cauda equina syndrome
What is most frequently compressed in paracentral herniation of L4/5
L5 root (transversing root)
What is sciatica
Radicular leg pain caused by irritation or compression of the nerve roots contributing to sciatic nerve (L4, L5, S1, S2 and S3)
Sciatica pain
Back and buttock and radiates to dermatome supplied by affected nerve root.
Distribution of pain in sciatica L4 L5 and S1
L4- anterior thigh, anterior knee, medial leg
L5- lateral thigh, lateral leg, dorsum of foot
S1- posterior thigh, posterior leg, sole of foot
What is cauda equina syndrome
Can be Prolapsed intervertebral disc when there is a canal filling disc- compresses lumbar and sacral nerve roots within the spinal canal
Other causes- tumours, spinal infection, stenosis secondary to arthritis, fracture, haemorrhage and ankylosis spondylitis
Red flag symptoms of cauda equina syndrome
- Bilateral sciatica
- Parianal numbness
- Painless retention of urine
- Urinary/faecal incontinence
- Erectile dysfunction
Treatment of cauda equina syndrome
Surgical decompression within 48 hrs of onset for good prognosis
Outcome of untreated cauda equina syndrome
Chronic neuropathic pain, impotence, catheters, faecal incontinence, loss of sensation or weakness requiring a wheelchair
What is spinal canal stenosis
Abnormal narrowing of the spinal canal that compresses either the spinal cord or nerve roots - tends to affect elderly
Spinal canal stenosis can occur due to
Disc bulging, facet joint osteoarthritis, ligamentum flavum hypertrophy
(Or compression fractures, spondyolisthesis, trauma)
Symptoms of spinal canal stenosis
- Discomfort whilst standing
- Discomfort or pain in shoulder, arm or hand (cervical stenosis) or lower limb (lumbar stenosis)
- Bilateral symptoms
- Numbness/weakness at or below level
- Neurogenic claudcation
Most common forms of spinal stenosis
Lumbar then cervical
What is neurogenic claudication
Symptom- patient reports pain or pins and needles in legs on prolonged standing and walking. Radiates in sciatica distribution.
What does neurogenic claudication result from
Compression of spinal nerves as they emerge from the lumbosacral spinal cord
Leads to venous engorgement of nerve roots during exercise, reduced arterial inflow and transient arterial ischeamia
Present in one or both legs
What relieves neurogenic claudication
Rest, change in position, flexion of spine.
What is spondylolisthesis
Anterior displacement of vertebra above relative to vertebra below. Can be congenital, isthmic, degenerative, traumatic, pathological or iatrogenic.
What happens in isthmic spondylolisthesis
Defect (such as stress fracture) develops in pars interarticularis. Complete fracture here is spondylolysis and then anterior displacement of upper vertebra is spondylolisthesis.
Symptoms and treatment for spondylolisthesis
Some asymptomatic
Discomfort- occasional lower back pain to incapacitating mechanical pain, sciatica from nerve root compression, and neurogenic claudication.
Treatment- surgical using screws and rods to stabilise spine
What technique spots spondylolysis on fractures
Scottie dog collar, or draw lines along edges.
What is Lumbar puncture
Withdrawal of fluid from subarachnoid space of lumbar cistern. Diagnostic test for CNS disorders including meningitis, MS etc…
How do you perform lumbar puncture
- Patient lie on side with back and hips flexed
- Insert between L3 and L4 or L4 and L5 vertebrae
- Find plane transecting iliac crests (usually passes through L4 spinous processes)
- No danger of damaging spinal cord
- 4-6cm in adults, needle pops through ligamentum flavum
- Punctures dura and arachnoid, enters lumbar cistern
- CSF escapes when stylet removed
Herpes zoster (shingles) key points
Viral infection, skin of single dermatome
Reactivation of varicella zoster virus (chickenpox)
Virus travels through a cutaneous nerve and remains dormant in dorsal root ganglion
When host is immunosupressed, VZV reactivates and travels through peripheral nerve to skin of a single dermatome
