Spinal Diseases Flashcards
What are some causes of Lower back pain.
- Mechanical back pain
- Lumbar disc herniation
- Cauda equina
- Lumbar stenosis
- Malignancy
- Trauma
- Infection (e.g. TB)
What is the most common cause of back pain?
Mechanical back pain.
What causes Mechanical Back pain?
Lots of factors:
- Obesity
- Lack of Exercise
- Strain on paraspinal muscles
- Facet joint OA
What age do people typically get mechanical back pain?
Between 20 and 55 years old.
What things may a patient complain with if they have mechanical back pain?
Morning stiffness which resolves with movement.
Pain which is made worse by prolonged sitting or when rising from seated.
What kind of pain can patients get if the facet joints get hypertrophied?
Referred pain from the nerve supplying the facet joint.
- Mimics Sciatica
- However, doesn’t radiate below the knee.
What are some red flags for low back pain?
Age >60 or <20 yrs.
Pain not improved by rest.
Pain waking patient in the night.
Urinary retention/incontinence and faecal incontinence.
Saddle Anaesthesia.
Malignant Hx.
Unexplained Wt loss.
Fever, Immunosuppression or IV drug Abuse.
What does a Lumbar disc herniation describe?
When the nucleus herniates through a tear in the annulus ring and compresses the adjacent nerve roots.
What levels are the most common for lumbar disc herniation?
L4/5 and L5/S1
What is the likely mechanisms of injury for Lumbar disc herniation in old vs young patients?
Young: Strain on the spine e.g. carrying heavy loads.
Old: Due to Degeneration of the vertebrae or spondylosis.
What is Radiculopathy?
Dysfunction of a nerve root causing a dermatomal sensory deficit with weakness of the muscle groups supplied by that nerve.
What is Sciatica?
Pain along the sciatic nerve usually due to compression of its nerve roots (L4-S3).
What is the pain pattern in sciatica?
Shooting pain radiating from the buttocks down to the posterior knee/leg.
Pain can be exaggerated by coughing or sneezing.
What is a positive Straight leg raise in Sciatica?
- Patient lying on their back.
- Lift patients leg with knee straight.
- If angle to which the leg can be raised before eliciting the patients sciatic pain is <45 then the test is said to be positive.
L5/S1 prolapsed intervertebral disc (root involved is S1).
What are the signs seen clinically?
- Pain along the posterior thigh with radiation to the heel.
- Weakness of plantar flexion (on occasion)
- sensory loss in the lateral foot.
- Reduced or absent ankle jerk.
L4/5 prolapsed intervertebral disc (root involved is L4).
What are the clinical signs seen?
- Pain along the posterior or posterolateral thigh with radiation to the dorsum of the foot and great toe.
- Weakness of dorsiflexion of the toe or foot.
- Parasthesia and numbness of the dorsum of the foot and great toe.
- Reflex changes unlikely.
L3/4 prolapsed intervertebral disc (root involved is L4)
What are the signs seen clinically?
- Pain in anterior thigh
- Wasting of Quadraceps muscle.
- Weakness of the Quadraceps function and dorsiflexion of the foot.
- Diminished sensation over the anterior thigh, knee and medial aspect of lower leg.
- Reduced knee jerk.
What are the Indications for surgery in a Lumbar disc prolapse (discectomy)?
- Failure of conservative Tx (physiotherapy and analgesia) - First line management.
- Central disc prolapse (Bilateral sciatica or sphincter disturbance, diminished perineal sensation)
- Tumour
- Neurological deficits.
How is Cauda-equina usually diagnosed?
- Lumbosacral MRI and Digital rectal exam to assess for lack of anal sphincter tone and perianal numbness.
What are the common causes of Lumbar Spinal Stenosis?
- Hypertrophy of facet joints and Ligamentum flavum.
- Protruding intervertebral discs.
- Spondylolisthesis.
What are the symptoms caused in Lumbar Stenosis?
Neurogenic claudication.
- unilateral or bilateral hip, buttock or lower extremity pain or burning sensation.
Made worse with standing or back extension and relieved by sitting, lumbar flexion or walking uphill.
What does Neurogenic Intermittent Claudication refer to in Spinal Stenosis?
Leg weakness, tingling and numbness which can be accompanied by paresthesia.
What is Cervical Spondylosis?
A Degenerative arthritic process involving the cervical spina and affecting the intervertebral disc and zygapophyseal joints.
Does a degenerative cervical myelopathy cause upper or lower motor signs?
Upper
What occurs to the cervical disc with age in Cervical Spondylosis?
Reduction of water content and fragmentation of the nucleus pulposus causing a degenerative problem
What are the clinical features of Cervical Spondylosis?
- Radiculopathy - lateral compression of a nerve causes LMN signs in the upper and lower limbs.
- Myelopathy
- Radiculopathy and Myelopathy often present together.
What is Degenerative Cervical Myelopathy?
Myelopathy that can result from spinal cord compression which causes Upper motor neurone signs with symptoms more prominent in the lower limbs.
In which patients does Degenerative cervical myelopathy usually occur?
Older patients.
- causes a deterioration of the patients gait and thus, is an important cause of falls in elderly.
What symptoms are seen in Degenerative cervical Myelopathy?
A progressive condition so early symptoms usually subtle.
- imbalance and disturbance of gait
- Clumsy hands (difficulty holding fork, buttoning shirt)
- Legs jump at night due to hyperreflexia.
What is the Gold Standard investigation of Degenerative cervical myelopathy?
MRI of the cervical spine Gold standard.
What is the treatment of Degenerative Cervical Myelopathy?
Early treatment offers best chance of full recovery (most present too late)
- Decompressive spinal surgery
- Aim of Tx prevent further deterioration rather than improving symptoms.
How do spinal cord compression syndromes occur?
- Mechanical compression
- Secondary ischaemic damage.
What are the two types of Spinal cord compression syndromes?
Acute - Trauma, tumours (haemorrhage or collapse), Infection or spontaneous bleed.
Chronic - Degeneration (spondylosis), Tumours, Rheumatoid Arthritis.
What is Anterior cord syndrome?
Cord infarction by the area supplied by the anterior spinal artery.
What clinical features would a patient complain of with anterior cord syndrome?
Paralysis and loss of pain and temperature below the level of injury.
Preserved proprioception and vibration sensation.
What is Brown-Sequard Syndrome?
Cord Hemisection damage - can occur due to penetrating injury or other cause.
What ipsilateral and contralateral symptoms with a patient with Brown-Sequard syndrome complain of?
- Ipsilateral upper motor neuron paralysis and loss of proprioception below the lesion.
- Contralateral loss of pain and temperature sensation beginning at 1 or 2 segments below the lesion.
What is central cord syndrome?
Caused by acute extension injury to already stenotic neck or syringomyelia or tumour,, causes a “Cape-like” Spinothalamic sensory loss (pain and temperature).
Where does weakness predominate in Central Cord syndrome?
Predominantly bilateral upper limb weakness > Lower limb (the fibres supplying the upper limbs in the lateral corticospinal tracts are more medial to the fibres supplying the lower limbs, hence a lesion in the central cord is more likely to damage the upper limb fibres)
- Dorsal columns preserved.
