spinal degenerative conditions

Question 1

describe intervertebral discs

Answer 1

Secondary cartilaginous joint

Largest avascular structure in the body

Made of two parts:
Annulus fibrosus - tough outer layer
Nucleus pulposus - gelatinous core

They resist rotational movements

Question 2

What connects the discs to the vertebral bodies

Answer 2

anterior and posterior longitduinal ligament

Question 3

What is the common direction of disc prolapses

Answer 3

Postero-laterally because the posterior longitudinal ligament thins out laterally

Question 4

What happens to the intervertebral discs due to ageing

Answer 4

decreased water content of the discs

Disc space narrowing

Degeneration seen on Xray

Aggravated by smoking

Question 5

Describe features of nerve root pain

Answer 5

Limb pain is worse than back pain

Pain is in a nerve root distribution

most settle in 3 months

root tension signs - e.g sciatic pain
root compression signs - loss of flexor reflexes in certain areas

Question 6

What is the management of nerve root pain

Answer 6

Physiotherapy

Strong analgesia e.g gabapentin

Refer after 3 months if no improvement for MRI scan

Question 7

What is a disc bulge

Answer 7

Common and asymptomatic

Question 8

What is a disc protrusion

Answer 8

Annulus is weakened but still intact

Question 9

What is disc extrusion

Answer 9

nucleus pulposis broken through annulus and herniated through

Question 10

What is disc sequestration

Answer 10

Desiccated disc material free in the spinal canal

Question 11

What is the most common lumbar disc prolapses

Answer 11

L4/5 and L5/S1 - sciatica

L3/4 - femoral neuralgia

Question 12

What happens when there is an L5-S1 disc prolapse

Answer 12

S1 nerve root

Sensory loss at the little toe and sole of the foot

Motor weakness at the plantar flexion of the foot

Absent ankle jerk

Question 13

What happens when there is a L4/5 disc prolapse

Answer 13

L5 nerve root

Sensory loss at the great toe and 1st dorsal web space

Motor weakness in the extensor hallicus longus

No loss of reflex

Question 14

What happens when there is a L3/4 disc prolapse

Answer 14

L4 nerve root

Sensory loss at the medial aspect of the lower leg

Motor weakness at the quads

Absent knee jerk

Question 15

What is cauda equina syndrome

Answer 15

Compression of the cauda equina - sacral nerve roots are compressed - bladder and anal sphincter control is lost - surgical emergency

Question 16

What is the management of cauda equina syndrome

Answer 16

admission
urgent MRI
emergency operation within 2 days of onset

Question 17

What are the causes of cauda equina syndrome

Answer 17

central lumbar disc prolapse - most common

tumours

trauma

infection

spinal stenosis

Question 19

What is the presentation of cauda equina syndrome

Answer 19

injury or a precipitating event

Location of symptoms bilaterally at the buttock and leg pain with varying dysaethesiae(numbness) and weakness
(Be aware of the weakness as the sensory nerve roots are more sensitive to compression than motor ones so if there is motor compression, the nerves are more severely compressed)

Bowel or bladder dysfunction

Perianal loss of sensation, loss of anal tone and anal reflex

Question 20

What is there raised suspicion of in a post op spinal surgery patient with increasing bilateral leg pain and urinary retention

Answer 20

Cauda equina syndrome

Question 21

What imaging is done for cauda equina syndrome suspicion

Answer 21

MRI

Lumbar CT myelogram if MRI is contraindicated - if any metal implants or metallic heart valves

Question 22

What is the treatment of cauda equina syndrome

Answer 22

within 48 hours from the onset of symptoms

discectomy can be done

Question 23

What is cervical and lumbar spondylosis

Answer 23

spondylosis - Another name for osteoarthritis

Degenerative changes at facet joints, discs, ligaments …

If it severe it can compress the whole cord causing myelopathy
with upper motor neuron signs

Upper motor neurons when the spondylosis is high up the spine

Question 24

describe facet joints

Answer 24

true synovial joints which allow flexion and extension

They are between the pedicle and lamina of a vertebra

Question 25

What is spinal claudication

Answer 25

Symptom - narrowing of the arteries of the lower limb which has pain when walking

Bilateral

sensory dysaesthesiae

Poss weakness e.g foot dropping

Takes several minutes to ease after walking

Worse when walking down hills because the spinal canal becomes smaller in extension

Question 26

What is the treatment of lateral recess stenosis

Answer 26

Nerve root injection

epidural injection of steroid

surgery

Question 27

What shape of spinal canal predisposes to central stenosis

Answer 27

trefoil canal

Question 28

What is the treatment of central stenosis

Answer 28

epidural steroid injection

Surgery

Question 29

What is foraminal stenosis

Answer 29

The nerve root is compressed as it emerges from the intervertebral foramen

Question 30

What is the treatment of foraminal stenosis

Answer 30

nerve root injection

epidural injection of steroid

surgery

Question 31

What is spondylolisthesis

Answer 31

One vertebrae has translated onto another

Question 32

What is spondylolysis

Answer 32

defect in the pars interarticularis - the posterior elements of the vertebrae is separated from the anterior

Question 33

What is the treatment of spondylolisthesis

Answer 33

lifestyle changes

Surgery if they have persistent pain with or without nerve root entrapment