Spine

Question 1

At what height does the spinal cord terminate?

Answer 1

L1/L2

Question 2

What are the red flags for sinister back pain?

Answer 2

Violent trauma
Minor trauma in osteoporosis
Alternating or bilateral sciatica
Weak legs
Weight loss or fever
Systemically unwell
Non-mechanical pain

Question 3

How do you test for an underlying herniated intervertebral disk?

Answer 3

Straight leg raise aims to strech the sciatic nerve and reproduce root pain

Question 4

What must you remember to do in a back exam?

Answer 4

Offer to do a PR to check for cauda equina

Question 5

What is the difference between an exiting and a traversing nerve root?

Answer 5

The exiting nerve root is leaving the spinal canal so a disk herniation below this point will not compress it. A traversing root stays in the canal to traverse to a lower level before exiting so can be compressed

Question 6

Where abouts are the sensory and motor nuclei located in the spinal cord cross sectionally?

Answer 6

Sensory nuclei are in the dorsal horn

Motor nuclei are in the anterior horn

Question 7

How should patients with acute mechanical lower back pain be managed?

Answer 7

Most is self resolving (90% by 6 weeks)
Focus is on; pain relief, exercises to improve function and lifestyle changes to prevent recurrence
-Encourage patients to exercise within the limits of the pain
-Analgesia helps to break the pain-muscle spasm cycle
-Warmth helps
-If acute spasm try muscle relaxant e.g. diazepam
-Cognitive therapy in groups helps tackle unhelpful beliefs

Question 8

What is radicular pain?

Answer 8

Nerve root pain that radiates into a dermatome

Question 9

What are the red flag signs for cauda equina?

Answer 9

Saddle anaesthsia and incontinence

Question 10

What are the signs of cervical myelopathy?

Answer 10

Pain of stiffness in neck
Paraesthesia
Loss of fine motor skills, coordination

Question 11

Which discs are most likely to prolapse?

Answer 11

The lumbar discs

Question 12

What is the typical presentation of a patient with a herniated disc?

Answer 12

They have severe pain on coughing, sneezing or twisting a few days after a strain
Pain may be confined to the lower lumbar region or radiate to the buttock or leg (sciatica) if there is nerve root compression
Pain worse on sitting as this increases pressure on the annular fibers

Question 13

What are the signs of a herniated disc?

Answer 13

There is limited forward flexion
L4/5 - L5 compression causes sensory loss over dorsum of foot - weakness in foot and big toe dorsiflexion
L5/S1 - S1 compression causes sensory loss of bottom of foot and posterolateral leg, weakness in plantar flexion of foot

Question 14

What are the investigations and management of disc prolapse?

Answer 14

Clinical history is usually enough
MRI if intervention is being contenplated or if cauda equina suspected
Treatment:
-Brief rest with early mobilisation
-Pain relief
-will resolve by itself in 90%

Question 15

What is spondylolisthesis?

Answer 15

This is the displacement (usually forward) of one of the lumbar vertebrae

Question 16

What tends to cause spinal cord stenosis in the lumber region?

Answer 16

Usually facet joint OA and osteophytes

Question 17

How do you differentiate spinal stenosis from disc herniation?

Answer 17

Spinal stenosis will be worse on walking and will cause spinal claudication
Pain on extension
Negative straight leg raise
Prefer to lean over
Disc herniation will be worse sitting, on flexion, positive straight leg raise

Question 18

What are the investigations and treatment for spinal stenosis?

Answer 18

MRI is preferred
Start with NSAIDs, epidural steroids and corsets
Then decompressice laminectomy

Question 19

What questions are important to ask for inflammatory back pain?

Answer 19

Any joint, bowel or eye involvement

Question 20

What are the signs and symptoms that are seen in spinal tumours?

Answer 20

Can compress any part of the cord so there can be LMN, UMN, Sensory loss and bowel and bladder dysfunction.

Question 21

What are the signs and symptoms of cauda equina syndrome?

Answer 21

This is compression below the conus medullaris and therefore causes LMN signs
Also:
-Poor anal tone
-Saddle anaesthesia
-Incontinence/retention of faeces or urine
-Paralysis

Question 22

What is the clinical presentation of discitis? how is it investigated and treated?

Answer 22

This is a type of pyogenic spine infection and features pain and movement restricted by spasm.
It does not often have any of the signs of infection other than a raised ESR, x rays show bone erosion and joint space narrowing, bone scans and MRI
Treatment:
-Antibiotics - vancomycin
-bed rest - back brace

Question 23

What is Pott’s disease and how is it treated?

Answer 23

This is a form of extrapulmonary TB that causes localised back pain and stiffness, spinal deformity is common
Always do CXR to check for pulmonary TB
Treat with antibiotics like osteomyelitis (vancomycin)

Question 24

What is a common cause of cervical myelopathy?

Answer 24

Cervical spondylosis (degenerative changes)