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MSK > Spinal Injury and Disease (Disc Herniation, Mechanical Back Pain, Sciatica, Cauda Equina, Cervical and Lumbar Sponylosis, Spondylolysis, Spondylolisthesis) > Flashcards

Spinal Injury and Disease (Disc Herniation, Mechanical Back Pain, Sciatica, Cauda Equina, Cervical and Lumbar Sponylosis, Spondylolysis, Spondylolisthesis) Flashcards

1
Q

What are the two main components of a healthy intervertebral disc?

A
  • Nucleus pulposus - distortable, incompressible semi-fluid gel. Mainly water (88%) + collagen and proteoglycans (very hydrophilic)
  • Annulus Fibrosus - surrounds nucleus pulposus. Provides resistance to multi-directional forces and accounts for the stability of the disc.
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2
Q

What is spondylosis?

A

Degeneration of the spine - also known as spinal osteoarthritis in the less broad sense

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3
Q

What are the degenerative consequences to spondylosis?

A
  • Formation of circumferential or radial tears within the annulus fibrosus
  • Sensitisation of the pain nociceptors that are located inside the annulus
  • Loss of disc height and facet joint arthrosis
  • Disc herniation and nerve root irritation - usually posterolateral
  • Hypertrophic changes resulting in spinal stenosis
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4
Q

What can cause nerve root irritation?

A
  • Nerve root compression by osteophytes
  • Central spinal stenosis
  • Spondylysis
  • Spondylolisthesis
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5
Q

What happens in IV disc herniation?

A

Tearing of annulus fibrosis and protrusion of the nucleus pulposus

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6
Q

What are the different types of disc herniations?

A
  • Bulge - generalised
  • Protrusion - annulus weakened but still intact
  • Herniation - through annulus but in continuity
  • Sequestration - dessicated disc material free in canal
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7
Q

What are the most common locations in the cervical vertebrae for IV disc herniations to occur?

A

C5/C6

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8
Q

What are the most common locations in the thoracic spine for IV disc herniation to occur?

A

T11/T12

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9
Q

What are the most common locations in the lumbar spine for IV disc hernation to occur?

A

By order of most common

  1. L4/5
  2. L5/S1
  3. L3/4
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10
Q

Where would sensory loss occur in an L5/S1 disc herniation?

A

S1 dermatome - Little toe and sole of foot

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11
Q

What nerve root is affected in an L5/S1 disc herniation?

A

S1 nerve root

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12
Q

What motor deficit would be seen in an L5/S1 disc herniation?

A

Plantar flexion of the foot - gastrocnemius, flexor hallucis longus, abductor digiti minimi

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13
Q

Which reflex would be affected in an L5/S1 disc herniation?

A

Ankle Jerk - S1/2 “buckle my shoe”

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14
Q

Which nerve root would be affected in an L4/5 disc herniation?

A

L5 Nerve Root

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15
Q

Where would sensory loss occur in an L4/5 disc herniation?

A

Great toe + 1st dorsal web space

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16
Q

What motor deficit would be experienced in an L4/5 disc herniation?

A

Dorsiflexion of ankle and toes - especially EHL

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17
Q

Which nerve root would be affected in an L3/4 disc hernation?

A

L4 nerve root

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18
Q

What motor deficit would be experienced in a L3/4 disc herniation?

A

Quadriceps weakness

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19
Q

What sensory deficit would occur in an L3/4 disc herniation?

A

Medial aspect of the lower leg

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20
Q

What reflex could be affected in a L3/4 disc herniation?

A

Knee jerk - L3/4 - “kick in the door”

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21
Q

What reflex could be affected in a L4/5 disc herniation?

A

NONE - both knee and ankle jerk remain normal as L5 nerve root supplies neither reflex

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22
Q

How does a prolapsed IV disc commonly present?

A
  • Severe pain
    • Worse on coughing, laughing, sneezing, twisting
    • Can be confined to lower lumbar area (lumbago) or radiate down buttocks or leg (sciatica)
  • Limited forward flexion and extension +/- lateral rotation
  • Nerve root specific signs - motor/sensory/reflex deficit
  • Positive Straight Leg Raise - Sciatica
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23
Q

In IV disc herniation, how is acute back pain produced?

A

Pressure of the nucleus upon the posterior longitudinal ligament and dura mater produces acute back pain.

Later, the herniation deviates laterally to impinge upon the traversing nerve root.

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24
Q

What could occur if a lumbar IV disc herniated centrally rather than posterolaterally?

A

Cauda Equina syndrome

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25
Q

What is mechanical back pain?

A

Back pain which is worse with movement and relieved with rest

Arises from any aspect of the motion segment (bones, joints, ligmanents, discs)

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26
Q

What percentage of those with mechanical back pain recover within 6 weeks?

A

90%

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27
Q

What advice would you give to someone with mechanical back pain?

A
  • AVOID BED REST - keep active
  • Simple analgesia
  • Workplace/activity assessement? - avoid twisting/lifting
  • Smoking cessation - interferes with disc nutrition
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28
Q

How would you manage someone with back pain plus signs of nerve root pain?

A

Most settle on their own (90% within 3 months)

  • Physio
  • Strong analgesia
  • Referral after 12 weeks - MRI
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29
Q

In someone with low back pain, what are the red flag symptoms/signs that would raise suspicion over the severity of the cause?

A
  • Traumatic injury
  • Urinary/faecal incontinence
  • Saddle anaesthesia
  • Progressive leg weakness/non-mechanical back pain
  • Severe abdo/low back pain
  • Gait disturbance
  • Weight loss
  • Neurological signs
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30
Q

In someone with low back pain, what risk factors could raise suspicion of more serious pathology?

A

Back pain, plus:

  • Previous malignancy
  • Systemic illness
  • Steroid use
  • HIV
  • IVDU
  • Thoracic pain - degenerative/metastatic change
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31
Q

What is sciatica?

A

Pain which radiates from the back into the buttock, thigh, calf and occasionally the foot. Numbness and paraesthesia occurs in same distribution

Onset can be sudden or gradual

32
Q

What test can be done to screen for sciatica?

A

Streight leg raise - produces pain around 40o

33
Q

What is cauda equina syndrome?

A

Syndrome that occurs due to compression of the cauda equina

34
Q

What can cause cauda equina syndrome?

A
  • Tumour
  • LD prolapse
  • Spinal stenosis
  • Traumatic injury
  • Epidural Abscess
  • Spinal surgery
  • Spinal Manipulation
  • Spinal epidural infection
35
Q

What are the clinical features of cauda equina syndrome?

A

LMN lesion

  • Back pain
  • Sensory loss in root distribution
  • Saddle anaesthaesia
  • Loss of anal tone and anal reflex
  • Urinary retention with overflow incontinence
  • Leg weakness - Asymmetrical, atrophic, areflexive paralysis
36
Q

If there was damage of S2-S5, what motor deficit would there be?

A

Sphincter deficit

37
Q

If there was damage at the level of S2-S5, what sensory deficit would be present?

A

Perianal and saddle (perineum, external genitalia)

38
Q

If there was damage at the S2-S5 level, what reflex would be affected?

A

Bulbocavernous reflex

39
Q

If you suspect someone has cauda equina syndrome, how should you investigate?

A

Clinical Diagnosis, followed by emergency imaging - MRI

40
Q

If you have confirmed someone has cauda equina, what is the next step to take in their management?

A

IMMEDIATE SURGICAL DECOMPRESSION - Within 48h

41
Q

What is the pathogenesis of spondylosis?

A
  • Disc joints become dehydrated and narrow ⇒ Facet joint degeneration due to increased axial loading
  • Annulus can become innervated and develop osteophytes at margins
  • Radiculopathy and central stenosis can develop
42
Q

What is cervical spondylotic radiculopathy (CSR)?

A

CAUSES LMN LESION

Nerve exiting the spinal cord/canal is pinched by either disc degeneration alone (i.e., herniated disc) or with moderate to severe degenerative changes, narrowing the root exit at the foraminal level

43
Q

What is cervical spondylotic myelopathy (CSM)?

A

CAUSES UMN LESION

Severe disc and facet degeneration with changes in spine alignment, such as kyphosis or spondylolisthesis, along with osteophyte formation

Lead to a significantly narrowed spinal canal and secondary spinal cord deformation

44
Q

What causes cervical spondylosis?

A
  • Spontaneous joint degeneration - acquired with age (>40)
  • Trauma
  • Surgery - Cervical
45
Q

How does cervical spondylosis present?

A
  • Usually asymptomatic
  • Neck Pain +/- muscle spasm
  • Decreased ROM
  • Signs of nerve/spinal cord compression
    • Level of lesion - LMN Radiculopathy - Arm pain +/- paraesthesiae, flaccid weakness
    • Below level of lesion - UMN myelopathy - Spastic weakness etc
46
Q

If someone with cervical spondylosis showed siminished relfexes in the arm, would they have cervical radiculopathy or myelopathy?

A

Cervical Radiculopathy

47
Q

If someone with suspected cervical spondylosis presents iwth increased relexes in the arm, would you suspect cervical radiculopathy or myelopathy?

A

Cervical myelopathy - damages descending pathways which inhibit reflex arc

48
Q

What is the peak age of onset of cervical spondylosis in males and females?

A
  • Male >60
  • Female >50
49
Q

How would you investigate suspected cervical spondylosis?

A
  • Imaging
    • Cervical MRI
    • Cervical X-Ray
50
Q

How would you manage someone with cervical spondylosis?

A

General

  • Physiotherapy
  • Traction therapy

Specific

  • NSAIDS
  • Muscle relaxants
  • Trigger point/facet joint injection

Surgery - IF CSR/CSM - Decompression

51
Q

How does lumbar spondylosis present?

A
  • Pain - particularly on extension
  • Neurogenic Claudication - sensory dysaesthesia, weakness, relieved on flexion of spine (e.g. sitting down), worse on extension (e.g. going downhill)
  • Stooped posture
  • Radiculopathic signs
52
Q

How would you investigate lumbar spondylosis?

A

Imaging

  • Plain x-ray
  • MRI
  • CT myelography
  • CT spine

Other

  • EMG walking test
53
Q

Where in the spine can lumbar spondylosis occur?

A
  • Central – spinal claudication
  • Lateral recess – symptoms in distribution of nerve root
  • Foraminal – pressure on nerve root – individual nerve root distribution
54
Q

How would you treat someone with lumbar spondylosis?

A

General

  • Activity modification +/- Use of physical aids
  • Physiotherapy
  • Spinal manipulation/Massage

Pharmacological - NSAIDS, Paracetamol, Nerve root injection, Epidural steriod injection

Surgery

55
Q

What is spondylolysis?

A

Defect/stress fracture of pars interarticularis - part between the superior and inferior facets

56
Q

What is spondylolysis caused by?

A

Trauma - Stress fracture of vertebrae

Pars interarticularis vulnerable to fracture during hyperextension combined with rotation

57
Q

How does someone with spondylolysis present?

A
  • Pain +/- radicular signs - worsened by hyperextension
  • Positive Stork test
  • Excessive lordotic posture
  • Unilateral tenderness
58
Q

How would you investigate spondylolysis?

A

Imaging - X-Ray, CT, MRI, Bone scan

59
Q

What is spondylolisthesis?

A

Displacement of one lumbar vertebrae on the vertebrae below

60
Q

Which direction does spondylolisthesis usually occur?

A

Forward

61
Q

Where does spondylolisthesis most commonly occur?

A

L5/S1

62
Q

What classification system is used to radiographically classify spondylolisthesis?

A

Meyerding Classification

  • Grade 1 - 0 to 25%
  • Grade 2 - 25 to 50%
  • Grade 3 - 50 to 75%
  • Grade 4 - 75 to 100%
  • Spondyloptosis - body of L5 vertebra sitting in front of S1
63
Q

What can cause spondylolisthesis?

A
  • Spondylosis - degenerative spondylolisthesis
  • Traumatic
  • Congenital malformation
64
Q

How does spondylolisthesis present?

A
  • Can be asympotomatic
  • Pain - dull ache +/- sharp sciatic pain
  • Tight hamstrings ⇒ waddling gait
  • Positive straight leg raise
65
Q

How would you investigate spondylolisthesis?

A

Imaging - X-ray and MRI

66
Q

How would you manage someone with sponylolisthesis?

A
  • Conservative - bracing and physio - temporary relief
  • Surgery - spinal fusion (essential for grade III-V)
67
Q

How would you manage someone with spondylolysis?

A
  • Conservative - e.g rest + bracing
  • Injection therapy
  • Surgery
68
Q

What is lumbar spinal stenosis and lateral recess steonsis?

A

Generalised narrowing of the spinal canal or its lateral recesses causing serve ischaemia ⇒ SPINAL CLAUDICATION

Typically caused by facet joint OA or osteophytes

69
Q

What are red flag signs of mechanical back pain?

A
  • Past Hx of Ca, steroids, HIV
  • First acute onset <20/>50
  • Non mechanical pain
  • Thoracic pain
  • Weight loss
  • Systemically unwell
  • Widespread neurology
  • Structural deformity/trauma
70
Q

If a patient had back pain which got worse throughout the day with early morning stiffness, what would be the most likely cause?

A

Mechanical back pain/OA

71
Q

If a patient had back pain which was worst in the morning and got better on exertion/throughout the day, what would be the most likely cause be?

A

Inflammatory back pain e.g. Ankylosing spondylitis

72
Q

If someone had back pain which woke them at night/was present at night, what would be important to exclude?

A
  • Infection
  • Malignancy
73
Q

Where would pain be experienced in L1 nerve root compression?

A

Inguinal region

74
Q

Where would pain be present in L2/3/4 nerve root compression?

A

Back, radiating into anterior thigh, and at times medial lower leg

75
Q

Where would L5 nerve root compression pain be felt?

A

Back, radiating into buttock, lateral thigh, lateral calf and dorsum of foot and great toe

76
Q

Where would pain from an S! nerve root compression be felt?

A

Back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot

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