Spine Flashcards
What is Hoffman’s reflex
Hoffmann’s reflex, is a finding elicited by a reflex test which verifies the presence or absence of problems in the corticospinal tract. It is also known as the finger flexor reflex. The Hoffman reflex has also been used as a measure of spinal reflex processing (adaptation) in response to exercise training.
The test involves tapping the nail or flicking the terminal phalanx of the middle or ring finger. A positive response is seen with flexion of the terminal phalanx of the thumb.
What is the grip and release test?
Grip and release fingers as fast as possible repeatedly for 10 seconds
Any age group should be able to do at least 20 to be classed as normal
Shows clumsiness of hands
What are cafe au lait spots?
What do they look like, other names, what are they seen in?
Café au lait spots or café au lait macules are flat, pigmented birthmarks. The name café au lait is French for “coffee with milk” and refers to their light-brown color. They are also called “giraffe spots” or “coast of Maine spots”.
They are caused by a collection of pigment-producing melanocytes in the epidermis of the skin.
These spots are typically permanent, and may grow or increase in number over time.
Café au lait spots are often harmless, but may be associated with syndromes such as Neurofibromatosis Type 1 and McCune-Albright syndrome.
What may help with mechanical back pain?
Activity
What pain may be associated with mechanical back pain?
Thigh pain
How do you manage mechanical back pain?
what speciality, managements, work, outcomes
-Managed in primary care
- Reassurance
- Simple analgesia REGULARLY
- Explanation
- Avoid bed rest, KEEP ACTIVE
- Early return to work
- 90% will settle in 6wks, but 60% recur
If mechanical back pain fails to settle what management can you consider?
Physiotherapy
May consider:
- Alternative therapy
- Facet joint injections
- Accupuncture
What aspects about the workplace increase risk of back pain?
what other lifestyle factors, what may help?
Some relation to physical work
-Not as clear cut as one would imagine
Care about bending and lifting is important
Ergonomics has relatively little effect
Smoking increases the problem
-?Reduces disc nutrition
What is the most important independent variable in back pain in the workplace?
Job satisfaction
What two ways can lumber discs prolapse?
What can they compress?
Posterolateral (common)
-Compress nerve root
Central
-Cauda equina if it comes on quickly
Describe the structure of intervertebral discs
Largest avascular structure in the body
Annulus fibrosus
-Tough outer layer
Nucleus pulposus
-Gelatinous core
+ collagen and proteoglycans (very hydrophilic)
Disc overall is kidney bean shaped
How do the fibres of the annulus fibrosis (collagen) run?
How does this effect function?
Obliquely and alternately between layers
Resist rotational movements
What is the normal aging process of the spine?
Decreased water content of discs
Disc space narrowing
“Degenerative” changes on X-rays
Degenerative changes in the facet joints
-Osteophytes
Aggravated by smoking etc
What is spondylolysis?
Spondylolysis (spon-dee-low-lye-sis) is defined as a defect or stress fracture in the pars interarticularis of the vertebral arch. The vast majority of cases occur in the lower lumbar vertebrae (L5), but spondylolysis may also occur in the cervical vertebrae.
What is spondylolisthesis?
Spondylolisthesis is the forward displacement of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a fracture. Backward displacement is referred to as retrolisthesis.
Spondylolysis (a defect or fracture of the pars interarticularis of the vertebral arch) is the most common cause of spondylolisthesis
Describe Nerve Root Pain
How common, how bad is it, distribution, management
Fairly common
Limb pain worse than back pain
Pain in a nerve root distribution (radicular)
-Dermatomes and myotomes
Again most will settle, about 90% in 3 months
Physiotherapy
Strong analgesia
Referral after 12 weeks
-Imaging MRI
Disc problems will be described by radiologists using terms like Bulge, Protrusion, Extrusion, Herniation, Sequestration
Disc Bulge -> nucleus pulposis bulging into annulous fibrosis
Protrusion -> annulous weakened but still intact
-neck of pulposis larger than head
Extrusion -> annulous weakened but still intact
-Head of pulposis larger than neck
Herniation -> through annulus but in continuity
Sequestration -> dessicated disc material free in canal
How common are thoracic intervertebral disc prolapses?
what vertebrae are most commonly effected?
What lumbar vertebrae are most effected?
What is the most common prolapse?
Usually L4/5 (45%)
L5/S1 (40%)
L3/4 (10%)
Most are posterolateral
-Posterior longitudinal Ligament weakest
What are the causes of cauda equine syndrome?
Usually due to central lumbar herniated disc
Tumours Trauma Spinal stenosis Epidural abscess Iatrogenic (spinal manipulation, spinal epidural, surgery)
What are the clinical features of cauda equine syndrome?
Injury or precipitating event
Location of symptoms
-Bilateral buttock and leg pain + varying dysaethesia + weakness
Bowel or bladder dysfunction
-Urinary retention +/- incontinence overflow
Saddle anaesthesia, loss of anal tone and anal reflex
High index of suspicion in spinal post-op patients with increasing leg pain in presence of urinary retention
How do you investigate cauda equina syndrome?
MRI
If contraindicated, then lumbar CT or myelogram
What is the treatment for caude equina syndrome?
Surgical emergency
Operate ASAP
-Within 48hr
(stastistically significant improvement and difference if surgery
How many undergoing discectomy for cauda equina syndrome do NOT regain normal urinary function?
How many with motor deficits never regain full power?
How many with sensory deficits never regained normal sensation?
30%
25%
33%
How many undergoing discectomy for caude equina syndrome do NOT get normal perianal parasthesiae back?
How many have persistent sexual dysfunction
25%
26%
Cervical and lumbar spondylosis sees degenerative change in which two places?
Facet joints
Discs
What may cause loss of consciousness in cervical spondylosis?
Vertebral artery passing through foramina transversaria may get nipped/occluded in cervical spondylosis causing may lose consciousness
What is the treatment of cervical spondylosis?
Nonoperative
Describe the ligaments of the spine
Anterior Longitudinal Ligament
-Along the front of the vertebral bodies (broad, strong)
Posterior Longitudinal Ligament
-Along the backs of the vertebral bodies (i.e. front of the spinal canal; narrower)
Ligamentum Flavum
-Between laminae
Interspinous and supraspinous ligaments
-Between spinous processes
Intertransverse Ligament
-Between transverse processes
How do you distinguish spinal claudication from vascular claudication
Spinal usually bilateral
Sensory dysaesthesiae
Poss weakness (foot drop- tripping)
Takes several minutes to ease after stopping walking
Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle
What are the 3 types of spinal stenosis?
Lateral recess stenosis
Central stenosis
Foraminal stenosis
What are the treatment options for lateral recess stenosis?
Nonoperative
Nerve root injection
Epidural injection
Surgery
What is the treatment of central stenosis?
Nonoperative
Epidural steroid injection
Surgery
What is the treatment for foraminal stenosis?
Nonoperative
Nerve root injection
Epidural injection
Surgery
What are the symptoms of spondylolysis?
Low back pain
Occasionally radicular symptoms
How do you investigate spondylolysis?
Plain radiographs
CT
MRI
Bone scan
WHat is the treatment of spondylolysis?
Nonoperative
Injection therapy
Surgery
What are the two ways to classify spondylolisthesis?
Radiographic (Meyerding)
Aetiologic (Wiltse)
What are the 5 Aetiological (Wiltse) classifications for spondylolisthesis?
Congenital Isthmic Degenerative Traumatic Pathologic
What is spondyloptosis in spondylolisthesis?
Body of L5 sitting in front of S1
What are the symptoms of spondylolisthesis?
Often vary with type of spondylolisthesis
What is the treatment for spondylolisthesis?
Depends on symptoms
- Conservative with lifestyle changes
- Surgery for persistent pain +/- nerve root entrapment
