Spinal Disorders Flashcards
Lower back pain can be a sign of what?
Malignancy Infection Fracture Cauda Equina Syndrome Inflammatory disease for spine
What are the red flags for malignancy in the spine?
History of cancer
Unexplained weight loss
Failure to improve symptoms of pain
Peripheral neurology compromise
What are the red flags for fracture in the spine?
History of trauma
Corticosteroid use - weakens the bone
Age over 65 and female
Pain referred to the lower limbs - fractures can compress the nerve.
What are the red flags for infection in the spine?
Fever / Rigors Recent serious illness / infection Non-mechanical pain Diabetes Age over 65 History of spinal surgery / injection
What are the red flags for cauda equina syndrome in the spine?
Urinary retention - big indicator Perianal sensation loss Reduced anal tone Bilateral leg pain Erectile dysfunction
Urinary retention
Urinary retention is a condition in which your bladder doesn’t empty completely even if it’s full and you often feel like you really have to urinate.
Cauda equina syndrome effects where in the spine?
The nerve roots L1-S2
What common inflammatory spinal conditions exist?
Ankylosing spondylitis
Ankylosing spondylitis
Ankylosing spondylitis (AS) is a autoimmune arthritis that causes pain and stiffness in your spine. This lifelong condition, also known as Bechterew disease, usually starts in your lower back. It can spread up to your neck or damage joints in other parts of your body.
What are the red flags for an underlying inflammatory condition in the spine? (Ankylosing spondylitis).
Pain and prolonged morning stiffness
Commonly young males
Uveitis
Gluteal pain
Uveitis
Uveitis is a form of eye inflammation. It affects the middle layer of tissue in the eye wall. They include eye redness, pain and blurred vision.
Lumbar disc herniation symptoms
Symptoms of a slipped disc include lower back pain, neck pain and difficulty bending your back.
How does acute cauda equina compression present?
Bilateral pain in both legs. Saddle anaesthesia (perianal). Urinary retention and loss of anal tone leading to bowel incontinence.
Spondylosis
Degenerative disc disease - is part of the normal ageing process and can lead to mechanical back pain. Spondylosis can lead to disc herniation and spinal stenosis.
What are the degrees of disc herniation?
Disc protrusion
Nuclear extrusion
Sequestered nucleus
Disc protrusion
Disc protrusion - the ruptured nucleus distorts the outermost fibers of the annulus causing them to bulge outward. The term “prolapsed disc” is synonymous with protrusion or bulging.
Nuclear extrusion
Nuclear extrusion - a complete split in the annulus that allows nuclear material to leak out into the surrounding
spaces. The protruded material remains attached to the nuclear material remaining inside the disc.
Sequestered nucleus
Sequestered nucleus - the extruded nuclear substance is no longer attached to the material remaining inside of the disc. The sequestered fragment(s) may float around the spinal canal and become totally remote from the site from which it originally extruded.
Why can disc herniation cause sciatica?
Most disc herniations in the canal occur lateral to the margins of the PLL. This puts the disc herniation in a position to physically contact and exert pressure on the exiting nerve root at
that level.
The individual may begin experiencing
pain down the back of the leg or sciatica.
Explain sciatic pain.
Sciatica can be caused by tension (stretching) mechanism of the nerve root over the bulging disc.
A mechanical compression of the nerve root between the bulging disc material and the posterior canal structures i.e stenosis.
Explain crualgia vs sciatica
Cruralgia = pain referred to above the knee: L1, L2, L3 nerve root compression
– Sciatica = pain referred to below the knee: L4, L5, S1 nerve root compression
Crualgia indicates which nerve roots are affected?
L1 L2 L3
Sciatica indicates which nerve roots are affected?
L4 L5 S1
What are the symptoms of nerve root compression?
– Motor weakness in IP (L1,L2), QF (L2, L3)
– Motor weakness in TA (L4)
– Motor weakness in EHP/EDC (L5) foot drop
– Motor weakness in plantar flexion (S1)
L4 palsy affects where?
Tibia and dorsiflexion of the foot - appears as a foot drop when walking.
What are the signs of spinal infection?
Tender spine
Raised temperature
High WCC
High ESR and CRP
What is the difference between cauda equina syndrome and conus medullaris?
Cauda equina typically causes severe pain, while conus medullaris results in mild to moderate pain, if any pain at all is present. Conus medullaris can be caused by an injury, lesion, or infection, while cauda equina is almost always caused by a lesion or infection.
Cauda equina syndrome
Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control.
What are the symptoms of cauda equina syndome?
Back pain, radicular pain down the legs, asymmetric, atrophic, areflexic, paralysis of the legs. Sensory loss in root distribution. Loss of sphincter tone.
Cauda equina results from compression where?
Compression of the roots distal to L1.
What can cause cauda equina?
Disc prolapse (1-2% of all lumbar disc herniations)
Trauma (fracture, dislocation)
Stenosis (usually with acute disc herniation)
Epidural Infection (iatrogenic or haematogenous)
Tumours (compression, epidural spread)
Why do patients with cauda equina initially present with pain?
Larger fibres (motor/joint position/light touch) less susceptible than smaller fibres (pain/parasympathetic).
A nerve can be compressed for up to 6-8hours after which it will become ischaemic.
A nerve can be compressed for up to 6-8hours after which it will become ischaemic.
Why are males less susceptible to permanent bladder damage from overdistension?
Males do not have a bladder and so can hold a larger volume of urine in their bladder. Therefore more attention is needed towards females presenting with bladder retention symptoms.
Spinothalamic tract detects…
Soft touch, temperature and pain.
Summarise bladder dysfunction in cauda equina syndrome.
Infrasacral - Below S2 - Conus/cauda equina/peripheral nerves. Results in:
Detrusor areflexia
Overflow incontinence
Note: Suprasacral above S2 due to spinal cord injury and tumours results in: Detrusor hyperreflexia.
What are the three types of cauda equina syndrome?
Early CESE
– Bilateral leg pain and altered sensation
– Perianal region decreased sensation
– Lower limb bilateral motor power abnormality
Incomplete CESI
– As above + reduced sphincter function
(bowel and bladder)
CESR (Retention) -
– Inability to pass urine or control bowel.
How is cauda equina syndrome managed?
CESE - monitor, MRI
CESI - urgent operative decompression < 24h
CESR - operative decompression
Why does cauda equina usually present with bilateral pain but unilateral motor deficit?
The nerve root pain fibres are smaller and more susceptible to compression where as the motor fibres are larger and so respond less to the compression over time.
What are the outcomes for people with cauda equina?
CESI - 75% return to acceptable normal sexual, bladder, social and bowel function. Chronic pain.
CESR - no return to acceptable normal sexual, bladder, social and bowel function. Chronic disabling pain.
