Spine Flashcards
What are the different segments of the spine?
- Cervical
- Thoracic
- Lumbar
- Sacrum
- Coccyx
How many vertebrae are there in the lumbar spine?
5
What are the lumbar movements?
- Flexion 50 degrees/Extension 30 degrees
- Side (lateral) Flexion 20-30 degrees
- Rotation (only a few degrees)
Describe the structure of the lumbar spine.
- No foramen transversaria / facets for ribs
- Stouter and stronger than other regions
- Kidney-shaped body
- L5 wedge shaped (deeper anteriorly)
- Spines project horizontally backwards
- Interbody joints (vertebral bodies)
- Zygapophyseal (facet joints)
Which part of the spine receives the most stress?
the lumbar spine
What are spinous processes?
- short, flat and hatchet shaped
- easily seen when bending forward
- robust and projects directly backward as adaptations for attachments of large muscles
How is rotation prevented in the lumbar spine?
the facets of articular processes of the lumber vertebrae are orientated so that they lock together and provide stability
What are (3) types of disc herniation?
- Annulus protrusion (prolapse)
- Nuclear extursion
- Sequestration
What is annulus protrusion (prolapse)?
disc bulges without rupture of the annulus fibroses
What is nuclear extursion?
annulus fibroses is perforated and part of the nucleus pulposes moves to the epidural space
What is sequestration?
formation of discal fragments from the annulus fibroses and nucleus pulposes outside the disc proper
What are the signs and symptoms of lumbar spinal stenosis?
- aching
- cramping
- tingling
- heaviness
- weakness of legs brought by walking or standing
- eased by sitting or leaning forward
How does lumber spinal stenosis occur?
due to the narrowing of the area of the spine that contains the nerves or spinal cord
–> can lead to irritation or compression of the nerves which travel down the legs
What is the cauda equina?
a group of nerves and nerve roots stemming from the distal end of the spinal cord (typically levels L1-L5), and contains axons of nerves that give both motor and sensory innervation to the legs, bladder, anus, and perineum
How many fused vertebrae make up the coccyx?
4
How can L5 root compressions occur?
- degeneration of the spine
- decreased disc space
- growth of osteophytes on facet joints
- thickening of ligaments
What are (3) L5 root compression injuries?
- disc prolapse (commonly a lifting injury)
- fracture
- spondylolisthesis (slip of one lumbar vertebra on another)
How does osteoporosis link to L5 root compression?
links to degeneration + loss of space between discs, and lack of space for nerve roots
Where does the iliolumbar ligament attach to?
L5-S1
What does the iliolumbar ligament restrict?
lateral flexion
Describe spondylolisthesis.
a condition occurring when one vertebral body slips with respect to the adjacent vertebral body
What are (5) main ligaments in the lumbar spine?
- anterior + posterior longitundinal ligaments
- ligamentum flava
- interspinous supraspinous ligaments
- iliolumbar ligament
- lateral lumbosacral ligament
What are (6) deep back muscles?
- spinalis
- longissimus
- iliocostalis
- spinalis thoracis
- longissimus thoracis
- iliocostalis lumborum
What are (3) superficial extensors of the back?
- illiocostalis
- spinalis
- longissimus
What are (3) deep extensors of the back?
- rotators
- semispinalis
- multifidous
What are (3) stabilizer muscles of the trunk?
- transversus
- abdominus
- multifidus
What are (3) mobilizer muscles of the trunk?
- erector spinae
- rectus abdominus
- quadratus lumborum
What are (4) trunk (abdominal) muscles?
- transversus abdominis
- internal oblique
- external oblique
- rectus abdominis
What are modifiable risk factors of low back pain (LBP)?
- physical activity level
- cognition + emotions
- environment
- socioeconomic
- cultural
- work
- home
- stress
- sleep
What are (3) non-modifiable factor of low back pain (LBP)?
- genetics
- gender
- life stage
How many nerve roots make up the cauda equina?
20
What must be done is someone presents with Cauda Equina Syndrome (CES)?
- Urgent referral for MRI
- Potential surgery
Why is cauda equina syndrome (CES) a medical emergency?
impairments can be permanent + life altering
How does Cauda Equina Syndrome (CES) occur?
as a result of direct compression on the lumbosacral nerve roots distal to the conus medialis
Cauda Equina.
- Provides innervation to the lower limb and sphincter (it includes the nerves which supply and control the bladder and bowel sensation to back passage and the bottom)
- Descends in the spinal canal from the L1 or L2 level (the nerves descend almost vertically until they reach their corresponding foramina)
What causes cauda equina syndrome (CES)?
- Large central disc prolapse at L4/5 or L5/S1
- Trauma
- Tumour
- Spinal canal stenosis
- Epidural haematoma
- Epidural abscess/post-op complications
What are the ‘red flag’ symptoms of Cauda Equina Syndrome (CES)?
- Severe low back pain (LBP)
- Sciatica: often bilateral but sometimes absent, (especially at L5/S1)
- Saddle and/or genital sensory disturbance
- Bladder, bowel and sexual dysfunction
- Disturbed/ataxic gait
- Objective findings (including sphincter tone on digital rectal examination)
What questions do you need to ask your patient in relation to Cauda Equina Syndrome (CES)?
- Do you have pain down both legs (sciatica)?
- Have you noticed any changes in your bowel, bladder or sexual function?
- Do you have difficulty controlling your bowel or bladder?
- Can you feel your saddle area when you wipe?
- Have you noticed any disturbances in your walking?
What is Metastatic spinal cord compression (MSCC)?
Metastases = secondary malignant growths that develop at a different site to the primary cancer
Cancer cells from the primary site can travel through the blood or lymphatic system to form new tumours
What are the most common primary cancers to metastasise to the spine?
- Lung
- Breast
- Prostate
What are the symptoms of Metastatic spinal cord compression (MSCC)?
- New + persistent localised back or neck pain
- Chest wall pain or other unexplained atypical pain
- Severe pain in lower back that gets worse or doesn’t go away
- Pain in the back that is worse when coughing, sneezing or straining
- Back pain that is worse at night
- Numbness, heaviness, weakness or difficulty using arms or legs
- A band of pain around the chest or abdomen or pain down an arm or leg
- Changes in sensation (e.g.: pins and needles or electric shock sensations)
- Numbness in the area around the saddle area
- Not being able to empty the bowel or bladder
- Problems controlling the bowel or bladder
What are the most common serious spinal diseases?
- Fracture
- Metastatic disease
- Spinal infection
- Cauda Equina Syndrome
- Axial Spondyloarthritis
What are some red flags/signs of cauda equina syndrome (CES)?
- Saddle anaesthesia
- Abnormal gait
- Changes / problems with bladder and/or bowel function
- Changes in sexual function
- Bilateral severe sciatica
- Severe low back pain (LBP)
- History of trauma
- History of cancer
- Severe, unremitting night pain
- Systemic upset or signs of infections
- Unexplained weight loss
What must be done is the patient is suspected to have Cauda Equina Syndrome?
refer to A&E (or for urgent medical assessment)
What is axial spondyloarthritis an umbrella term for?
for a group of rheumatological conditions affecting predominantly the spine and pelvis
How does Axial spondyloarthritis
classically present?
Back pain and stiffness, worse in the morning, eases with exercise
(Chronic, progressive inflammatory disease resulting in skeletal changes
Pain is constant with intermittent, severe flare ups)
What can Axial spondyloarthritis be associated with?
non-MSK symptoms like fatigue, IBS, eye symptoms
What does spinal infection include?
- Discitis
- Epidural abscess
- Septic facet joints
- Spondylitis
- TB
How do patients with spinal infection usually present?
- Severe, unremitting, non-mechanical spinal pain (but symptoms can take several weeks or months to become severe)
- Fever is common but not always present
What are some risk factors for spinal infection?
- HIV
- Recent surgery
- Malignancy
- Diabetes
Where is spinal metastasis most commonly found?
Thoracic Vertebrae
(but can be present in other areas of the spine + the local cord & soft tissues)
What is radiculopathy?
Neuropathic pain
- derived from the nerve itself or its connective tissue by mechanical or chemical stimulation
(5-10% LBP patients)
What can be the mechanical stimulation of radiculopathy?
Compression from a disc, osteophyte or stenosis
What can be the chemical stimulation of radiculopathy?
- Inflammatory chemicals
- Infection
What can radiculopathy be characterised by?
- Severe, referred pain (often burning, sharp or shooting in nature with more pain distally a common feature, (and minimal LBP not uncommon))
- Pain can refer along a dermatomal pattern, or along a specific nerve (e.g.: sciatic or femoral nerve)
- Often accompanied with neurological symptoms (P&N/numbness), and/or neuro integrity deficits (D, M and R changes).
Stenotic/Neurogenic Claudication.
- AGG standing/walking/extension
- EASE sitting/flexion
Discogenic
- AGG bending/flexion/cough/sneeze
- EASE prone/extension
What are some anatomical factors that can contribute to non-specific lower back pain (LBP)?
from the tissues as in more nociceptive/radicular pain patterns
What are some processing factors that can contribute to non-specific lower back pain (LBP)?
from the brain as in centrally driven pain patterns
What is spondylolisthesis graded based on?
the degree of slippage of one vertebral body on the adjacent vertebral body
What does spondylolisthesis cause (pain wise)?
radicular or mechanical symptoms or pain
