Spinal Symposium - Pt 2

Question 1

What is the difference between lateral disc and central disc protrusion?

Answer 1

Lateral compresses nerve root
Central compresses roots within cauda equina

Question 2

Describe intervertebral discs

Answer 2

Secondary cartilaginous joint
Annulus fibrosis and nucleus pulposus
Annulus may tear and nucleus prolapse

Question 3

Describe the fibres of the annulus fibrosis

Answer 3

Collagen runs obliquely and alternatively between layers
Resist rotational movements and disc fails with twisting movements

Question 4

What does the nucleus pulposus mainly consist of?

Answer 4

88% water
And collagen and proteoglycans
Decreased water content as age increases so disc space narrows

Question 5

What are pathological processes affecting the spine?

Answer 5

Tearing of annulus fibrosis and protrusion of nucleus
Nerve root compression by osteophytes
Central spinal stenosis
Abnormal movement

Question 6

Describe nerve root pain

Answer 6

Fairly common, limb pain worse than back pain and pain in nerve root distribution
Root tension signs and root compression signs
Dermatomes and myotomes

Question 7

What is the management for nerve root pain?

Answer 7

Most will settle - 90% in 3 months
Physio, strong analgesia, referral after 12 weeks and MRI

Question 8

What are the different types of disc problems?

Answer 8

Buldge - generalised
Protrusion - annulus weakened but still intact
Extrusion - through annulus but in continuity
Sequestration - desiccated disc material free in canal

Question 9

What is the most common cervical disc prolapse?

Answer 9

C5/6

Question 10

Describe thoracic disc prolapse

Answer 10

Less than 1% intervertebral disc prolapses
Mid to lower levels and most T11/12
Central, posterolateral and lateral herniations

Question 11

Describe lumbar disc prolapse

Answer 11

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

Question 12

What happens if prolapsed disc at L5/S1?

Answer 12

S1 nerve root affected
Little toe and sole of foot - sensory loss
Plantar flexion foot - motor weakness
Ankle jerk

Question 13

What happens if prolapsed disc at L4/5?

Answer 13

L5 nerve root affected
Great toe and 1st dorsal web space - sensory loss
EHL - motor weakness

Question 14

What happens if prolapsed disc at L3/4?

Answer 14

L4 nerve root affected
Medial aspect of lower leg - sensory loss
Quads - motor weakness
Knee jerk

Question 15

Describe cauda equina syndrome

Answer 15

Compression of cauda equina
Is a surgical emergency
Sacral nerve roots compressed - can result in permanent bladder and anal sphincter dysfunction and incontinence

Question 16

What is the aetiology of cauda equina syndrome?

Answer 16

Central lumbar disc prolapse
Tumours
Trauma or spinal stenosis
Infection - epidural abscess
Iatrogenic

Question 17

What are the clinical features of cauda equina syndrome?

Answer 17

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

Question 18

What happens in a delay of diagnosis for cauda equina syndrome?

Answer 18

Shapiro - USA
Surgical emergency

Question 19

What is used for radiographic evaluation of cauda equina syndrome?

Answer 19

MRI
If contraindicated then lumbar CT myelogram

Question 20

What is the treatment of cauda equina syndrome?

Answer 20

Operative
Within 48hrs

Question 21

What is the outcome of cauda equina syndrome?

Answer 21

30% undergoing discectomy did not regain normal urinary function
25% never regained motor deficits
33% never regained sensory deficits

Question 22

Describe cervical and lumbar spondylosis (OA)

Answer 22

Common
Degenerative change at facet joints, discs and ligaments
If severe it can compress whole cord causing myelopathy (UMN signs in limbs)

Question 23

What do the facet joints allow in the lumbar spine?

Answer 23

Allow mainly flexion and extension

Question 24

What are the ligaments of the spine?

Answer 24

Anterior and posterior longitudinal ligaments
Ligamentum flavum
Interspinous and supraspinous ligaments
Intertransverse ligament

Question 25

What can cause lumbar spondylosis?

Answer 25

OA of facet and disc joints
Also degeneration of ligaments…

Question 26

How is spinal claudication distinguished from vascular claudication?

Answer 26

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

Question 27

What are some types of spinal stenosis?

Answer 27

Lateral recess, central and foraminal stenosis

Question 28

What is the treatment of lateral recess stenosis?

Answer 28

Non-operative, nerve root injection, epidural injection and surgery

Question 29

What is the treatment for central stenosis?

Answer 29

Canal shape is important
Non-operative, epidural injection and surgery

Question 30

What is the treatment for foraminal stenosis?

Answer 30

Non-operative, nerve root injection, epidural injection and surgery

Question 31

What are the symptoms and treatments for spondylolisthesis?

Answer 31

Often symptoms vary with type
Treatment depends on symptoms
Conservative with lifestyle changes
Surgery of persistent pain and possible nerve entrapment