Spine/Back Flashcards
Where does the spinal cord run to?
L1
What is the name of the structure located at L1?
Conus medullaris
What is the name of the structure following the conus medullaris at L1?
Cauda equina
What is myelopathy?
Injury to the spinal cord due to compression (not the cauda equina)
What is radiculopathy?
Injury affecting the spinal nerves/roots (often due to compression)
Where are spinal nerves located?
Intervertebral Foramen (located between superior and inferior facet joints)
What are the most common general presentations of spinal pathologies?
Numbness
Weakness (function)
Pain
How does a radiculopathy typically present?
Pain radiates to affected spinal level (e.g sciatica)
What is it called when multiple nerve roots are compressed?
Claudication
What are the 2 types of claudication?
Neurogenic
Vascular
How can you differentiate between neurogenic claudication and vascular claudication?
Neurogenic = pain comes on as you walk, relief when flex spine, peripheral pulses normal
Vascular = pain all the time, relief when rest or lie down and hang legs off bed, peripheral pulses often affected and limbs can become cold
Potential skin changes
Why does Flexion in the spine offer pain relief with neurogenic claudication?
Typically caused by spinal stenosis
Flexion of the spine increases the diameter of the spinal canal by stretching the ligamentum flavum and opening larger spaces between the vertebra and intervertebral foramina
What do people typically complain about with claudication?
Dull aching
Jelly legs
Leg heavy
What are the 3 main changes that can occur when there are spinal cord pathologies?
Imbalance
Motor loss/changes
Sensory loss
What are the changes seen with UMN lesions?
Hypertonia
Hyper-reflexia
Atrophy of disuse
Clonus
+ve babinski sign
+ve Hoffmanns sign
What is hoffmans sign?
When you flick the middle fingers nail, the thumb flexes
This is suggestive of an UMN lesion
How do LMN lesions present?
What can it also be called?
Radiculopathy
Hypotonia
Hyporeflexia
Fasiculations
Atrophy of Denervation
Pain
What is spinal stenosis?
Narrowing of the spinal canal or foramina
What are some causes of spinal stenosis?
Herniated intervertebral disc
Tumour
Abcesses
Facet joint osteoarthritis
Ligamentum flavum hypertrophy
Fractures
How may lumbar stenosis present?
Lower back pain
Refered leg or gluteal pain
Neurogenic claudication
Lower limb weakness
What is the gold standard investigation if you believe someone may have a lumbar stenosis?
MRI lumbar sacral spine
What are the steps to managing lumbar stenosis?
Conservatively:
-NSAIDs (like naproxen) with PPI cover
-Physio (core strengthening and mobilisation)
-Weight loss
-Epidural steroids if others fail
Surgical fixation
How can cervical myelopathy (stenosis) present?
Neck pain
Can unilateral or bilateral (both arms or both legs or both arms and legs)
UMN signs
Lhermitte’s sign
Gait disturbance
Paresis (hand clumsiness)
Sensory disturbance
What is Lhermitte’s sign?
When the neck is flexed the patient experiences an electric shock/pain sensation running down their spine
What is the gold standard imaging to identify cervical myelopathy’s?
MRI whole spine
What is the management for cervical myelopathy?
Typically surgical fixation/decompression
What is spondylosis?
Degenerative changes of the spine/osteoarthtic changes of the spine
What are some of the anatomical changes seen in spondylosis?
Degeneration of intervertebral discs
Facet join oestoarthritis
Oesteophytes
Ligamentum flavum thickening
What is the management approach when it comes to spondylosis?
If no neurological signs treat as oesteoarthritis/mechanical back pain:
(Physio, weight loss, core strengthening, NSAIDs (naproxen with PPIs))
If neurological signs conservative first if possible like Neurological analgesia
What are some medications that are neurological analgesia/neurological pain killers?
Amitriptyline
Gabapentin
What part of the vertebra is involved within spondylolysis and spondylolithesis?
Pars interarticularis
What is spondylolysis?
Fracture of the pars interarticularis without subluxation
How does spondylolysis present?
Back pain
Muscles spasms
Pain my radiate to gluteal region
Pain worse on hyperextension of spine
What is the pars interarticularis?
Region of the vertebra between the superior and inferior articulating processes that contribute to the facet joints
What is spondylolisthesis?
Anterior displacement of the superior vertebra related to its inferior vertebra
Isthmic spondylolisthesis is when the subluxation occurs due to pars interarticularis defect
How are both spondylolysis and spondylolisthesis both conservatively managed?
Physio
Rest
Bracing
NSAIDs (PPI cover)
Surgery required sometimes
What are the potential causes of cauda equina syndrome?
Tumour
Abcesses
Disc herniation
Fracture
Iatrogenic
Fracture
Epidural haemotoma
What are the red flags for Cauda Equina Syndrome?
Saddle anaesthesia
Painless urinary retention/overflow incontinence
Faecal incontinence
Erectile dysfunction
Bilateral sciatica
Gait disturbance
What are the important investiagtions and examinations that should be done for suspected cauda equina?
MRI Whole spine
Post void bladder scan (retention?)
Anal tone/wink (DRE squeeze)
Saddle sensation
What is the management for cauda equina?
What time frame and why?
URGENT surgical decompression
Within 48hrs of sphincter disturbance otherwise permanent need to self catheterise, stoma bag, loss of sensation, paralysis etc…
What is back pain + fever until proven otherwise?
Spinal infection
What can cause spinal infections?
Dis it is
Epidural abscess
Vertebral oesteomyleitis
How can infections spread to the spinal cord?
Haematogenous
Direct inoculation (iatrogenic)
Adjacent spread
What are the red flags for a spinal infection?
Fever + Back pain
Immunosuppression (diabetes)
IV drug user
Chronic steroid use
Recent UTI
TB
What is the gold standard imaging for a spinal infection?
MRI whole spine contrast
What is the managemtn for a spinal infection?
Highly dependant on the cause
If necessary initiate sepsis 6 pathway
What are some spinal cancers?
Metastasis mainly
Lymphomas
Osteosarcoma
What are the red flags for spinal cancers?
Age<15. Age >50
Gradual onset/progressive pain or symptoms
Previous malignancy
Unexplained weight loss
Night sweats
What are the red flags for spinal fractures?
Old age
Trauma
Long term corticosteroids or NSAIDs
Hx oesteoporosis
Metabolic bone disease
What is mechanical back pain?
Back pain that is associated with the structures of the spine, muscles, intervertebral discs and ligaments that surround it
What are the signs/symptoms of mechanical back pain?
Lower back pain
Tight paraspinal muscles
Motor weakness/paraestehsia
Lower back stiffness
Refered gluteal pain
Positive straight leg raise test
What is the management for mechanical back pain?
Analgesia (NSAIDs/naproxen + PPI cover)
Physiotherapist
Weight loss
If sciatica amitriptyline or gabapentin
What is the gold standard imaging for mechanical back pain?
Don’t typical image:
Only if pain is persistent after conservative management or RED FLAGs for other pathology like Cauda equina, spinal infection etc….
What are some differentials for pain radiating to the limbs that’s not radiculopathy?
Myofascial pain
IT band syndrome
Meralgia paraesthetica
Piriformis syndrome
Refered pain (like from MI)
What is meralgia paraesthetica?
Compression of lateral cutaneous nerve of the thigh under the Inguinal ligament leading to paraesthesia in the antero-lateral aspect of thigh
What is Piriformis syndrome?
Spasms of the Piriformis muscle of the posterior thigh leads to compression of the sciatic nerve
