Spinal problems

Question 1

Give five causes of spinal cord compression

Answer 1

Tumour (primary/local or metastatic)
Abscess
Trauma
Central disc prolapse
Tuberculosis

Question 2

What are the major causes of lumbar back pain?

Answer 2

EMERGENCIES:

• spinal cord compression
• cauda equina syndrome
• osteomyelitis
• malignancy
• multiple myeloma

Mechanical problems

Inflammatory conditions

Question 3

What are the mechanical causes of lumbar back pain?

Answer 3

MECHANICAL:

• poor posture
• prolapsed disc
• fracture
• OA
• spondylolisthesis
• spinal stenosis

Question 4

What are the inflammatory causes of lumbar back pain?

Answer 4

INFLAMMATORY

• ankylosing spondylitis
• discitis
• Paget’s disease

Question 5

Describe the clinical presentation of spinal cord compression

Answer 5

Bilateral leg pain
Radicular (nerve root) pain
Paraesthesia below compression level
Upper/Lower motor neurone signs depending on location
Sphincter disturbance
Cauda equina syndrome (if lumbar region is compressed)

Question 6

Describe the pathology of intervertebral disc prolapse

Answer 6

Herniation of the nucleus pulposus through the annulus fibrosus, due to tearing of the AF.
Can be central (compresses spinal cord) and/or lateral (most commonly posterolateral, causes nerve root pain)

Question 7

Which region of the spine is most likely to suffer from a disc prolapse?

Answer 7

L4 / L5 / S1

Question 8

Describe the clinical presentation of a disc prolapse

Answer 8

Back pain (often lumbar)
Referred leg pain
Sciatica
Motor and sensory symptoms over the distribution of the affected nerve root

Question 9

How is a disc prolapse diagnosed?

Answer 9

Positive straight leg raise test (demonstrates nerve root irritation)
Confirmed on MRI

Question 10

Describe the treatment options for disc prolapse

Answer 10

Initial rest
Analgesia
Physiotherapy
Surgery (spinal discectomy)

Question 11

Give four types of intervertebral disc problem

Answer 11

Bulge
Protrusion
Extrusion
Sequestration

Question 12

What is cauda equina syndrome?

Answer 12

Compression of the cauda equina

- this is a surgical emergency

Question 13

List the possible causes of cauda equina syndrome

Answer 13

Central lumbar disc prolapse (most common)
Tumours
Trauma
Spinal stenosis
Chronic inflammation e.g. ankylosing spondylitis
Infection (epidural abscess)
Iatrogenic e.g. haematoma following spinal anaesthetic

Question 14

Describe the protocol for suspected cauda equina syndrome

Answer 14

Admission
Urgent MRI scan
High-dose dexamethasone (reduces oedema)
Emergency surgical decompression within 48 hours of onset

Question 15

Describe the presentation / red flags for cauda equina syndrome

Answer 15

Characteristic LMN symptoms:

• micturition disturbance: hesitancy and urgency
• faecal incontinence (sphincter dysfunction)
• increasing motor weakness + gait disorder
• saddle (perianal) anaesthesia

Note: symptoms can be variable/non-specific, so high index of suspicion is needed
Presence of UMN symptoms suggests cord compression rather than cauda equina

Question 16

What is spondylosis?

Answer 16

: spinal degeneration accompanied by pain. Is often used as a synonym for spinal arthritis.

Question 17

Describe the pathophysiology of spondylosis

Answer 17

Chronic disc degeneration with herniation of disc material, calcification and osteophytes (bony outgrowths forming along joint margins).

Question 18

How/why does spondylosis cause pain?

Answer 18

• Radiculopathy due to compression, stretching or angulation of the cervical nerve roots.
• Myelopathy due to compression, compromised blood supply or recurring minor trauma to the cord.

Question 19

What is spinal stenosis?

Answer 19

Narrowing of the spinal canal

Question 20

What causes spinal stenosis?

Answer 20

Degenerative changes

Rarely due to prolapse, malignancy or congenital narrowing

Question 21

What is the main symptom of spinal stenosis?

Answer 21

Spinal (neurogenic) claudication; painful cramping and weakness in the legs, usually bilateral

Question 22

When is neurogenic claudication most severe?

Answer 22

Exercise
Spinal extension
- walking down hills

Question 23

Describe the treatment options for spinal stenosis

Answer 23

Lifestyle changes, particularly weight loss
Analgesia
Physiotherapy
Surgery - spinal decompression

Question 24

What is spondylolisthesis?

Answer 24

Displacement of a vertebra, either forwards or backwards, usually in the L4/L5/S1 region

Question 25

What causes spondylolisthesis?

Answer 25

Ossification defect of the pars interarticularis; can be congenital or trauma-induced
Exacerbated by spinal hyperextension

Question 26

Describe the clinical features of spondylolisthesis

Answer 26

Chronic back pain on standing and exercise
Sciatica and radiculopathy can occur
ROM and exercise may be restricted

Question 27

What is spondylolysis?

Answer 27

A defect or stress fracture in the pars interarticularis of the vertebral arch.