Spinal Symposium - Pt 2 Flashcards
What is the difference between lateral disc and central disc protrusion?
Lateral compresses nerve root
Central compresses roots within cauda equina
Describe intervertebral discs
Secondary cartilaginous joint
Annulus fibrosis and nucleus pulposus
Annulus may tear and nucleus prolapse
Describe the fibres of the annulus fibrosis
Collagen runs obliquely and alternatively between layers
Resist rotational movements and disc fails with twisting movements
What does the nucleus pulposus mainly consist of?
88% water
And collagen and proteoglycans
Decreased water content as age increases so disc space narrows
What are pathological processes affecting the spine?
Tearing of annulus fibrosis and protrusion of nucleus
Nerve root compression by osteophytes
Central spinal stenosis
Abnormal movement
Describe nerve root pain
Fairly common, limb pain worse than back pain and pain in nerve root distribution
Root tension signs and root compression signs
Dermatomes and myotomes
What is the management for nerve root pain?
Most will settle - 90% in 3 months
Physio, strong analgesia, referral after 12 weeks and MRI
What are the different types of disc problems?
Buldge - generalised
Protrusion - annulus weakened but still intact
Extrusion - through annulus but in continuity
Sequestration - desiccated disc material free in canal
What is the most common cervical disc prolapse?
C5/6
Describe thoracic disc prolapse
Less than 1% intervertebral disc prolapses
Mid to lower levels and most T11/12
Central, posterolateral and lateral herniations
Describe lumbar disc prolapse
Usually L4/5 then L5/S1 then L3/4
Most are posterolateral - posterior longitudinal ligament weakest
Central disc may give pain in both legs or back pain only
What happens if prolapsed disc at L5/S1?
S1 nerve root affected
Little toe and sole of foot - sensory loss
Plantar flexion foot - motor weakness
Ankle jerk
What happens if prolapsed disc at L4/5?
L5 nerve root affected
Great toe and 1st dorsal web space - sensory loss
EHL - motor weakness
What happens if prolapsed disc at L3/4?
L4 nerve root affected
Medial aspect of lower leg - sensory loss
Quads - motor weakness
Knee jerk
Describe cauda equina syndrome
Compression of cauda equina
Is a surgical emergency
Sacral nerve roots compressed - can result in permanent bladder and anal sphincter dysfunction and incontinence
What is the aetiology of cauda equina syndrome?
Central lumbar disc prolapse
Tumours
Trauma or spinal stenosis
Infection - epidural abscess
Iatrogenic
What are the clinical features of cauda equina syndrome?
Injury or precipitating event, location of symptoms (bilateral buttock and leg pain), bladder or bowel dysfunction, PR exam for saddle anaesthesia and high index of suspicion
What happens in a delay of diagnosis for cauda equina syndrome?
Shapiro - USA
Surgical emergency
What is used for radiographic evaluation of cauda equina syndrome?
MRI
If contraindicated then lumbar CT myelogram
What is the treatment of cauda equina syndrome?
Operative
Within 48hrs
What is the outcome of cauda equina syndrome?
30% undergoing discectomy did not regain normal urinary function
25% never regained motor deficits
33% never regained sensory deficits
Describe cervical and lumbar spondylosis (OA)
Common
Degenerative change at facet joints, discs and ligaments
If severe it can compress whole cord causing myelopathy (UMN signs in limbs)
What do the facet joints allow in the lumbar spine?
Allow mainly flexion and extension
What are the ligaments of the spine?
Anterior and posterior longitudinal ligaments
Ligamentum flavum
Interspinous and supraspinous ligaments
Intertransverse ligament
What can cause lumbar spondylosis?
OA of facet and disc joints
Also degeneration of ligaments…
How is spinal claudication distinguished from vascular claudication?
Usually bilateral, sensory dysesthesia, weakness (drop foot - tripping), takes several minutes to ease after stopping walking and worse walking down hills as smaller cord smaller in extension
What are some types of spinal stenosis?
Lateral recess, central and foraminal stenosis
What is the treatment of lateral recess stenosis?
Non-operative, nerve root injection, epidural injection and surgery
What is the treatment for central stenosis?
Canal shape is important
Non-operative, epidural injection and surgery
What is the treatment for foraminal stenosis?
Non-operative, nerve root injection, epidural injection and surgery
What are the symptoms and treatments for spondylolisthesis?
Often symptoms vary with type
Treatment depends on symptoms
Conservative with lifestyle changes
Surgery of persistent pain and possible nerve entrapment
