Spine (Degeneration, Lower back pain and disc prolapse) Flashcards
What type of joints are faecet joints of the lumbar spine and what movements do they allow?
True synovial joints
Mainly flexion and extension
What types of joints are intervertebral discs of lumbar spine and what movements do they allow?
Secondary cartilaginous joints
Movement between vertebrae
Where is the anterior longitudinal ligament (ALL)?
Along the front of the vertebral bodies
Where is the posterior longuitdinal ligament (PLL)?
Along the backs of the vertebral bodies i.e. front of the spinal canal
Where is the ligamentum flavum?
Between laminae
Where is the interspinous and supraspinous ligament found?
Between spinous processes
Where is the intertransverse ligament found?
Between transverse processes
Where is the pain worse in nerve root pain?
Limb pain is worse than back pain
Presentation of nerve root pain
Pain (back, limbs)
Root tension signs
Root compression signs
Treatment of nerve root pain
most settle about 90% in 3 months
physio
strong analgesia
MRI
Normal ageing process of the spine
decreased water content of discs
disc space narrowing
“degenerative changes” on X rays
degeneration changes in faecet joints
What is the ageing process of the spine aggrevated by?
Smoking
Where are degenerative changes seen in cervical and lumbar spondylosis (OA)?
faecet joints
discs
ligaments
What can severe cervical/lumbar spondylosis cause?
Can compress the whole cord (not just the nerve roots) causing myelopathy
- UMN signs in limbs (increased tone, brisk reflexes etc)
What is lumbar spondylosis?
OA of faecet and disc joints (+degeneration of ligaments etc)
Who is spinal claudication/stenosis very common in?
patients > 60 y/o
Types of spinal claudication/stenosis
Lateral recess stenosis
Central stenosis
Foraminal stenosis
Treatment of lateral recess stenosis
non operative
nerve root injection
epidural injection
surgery
Treatment of central stenosis
non operative
epidural steroid injection
surgery
Treatment for foraminal stenosis
non-operative
nerve root injection
epidural injecton
surgery
Most common cause of spinal cord injuries
RTAs
sports and recreational activities
falls
Criteria/presentation of a complete injury (grade A) to spinal cord
No motor or sensory function
no anal squeeze
no sacral sensation
no chance of recovery
What is the grading system for spinal cord injuries?
ASIA grading
Presentation of incomplete injury of spinal cord
Some function still present below the site of the injury
ASIA grade A
Complete
no sensory or motor function preserved in sacral segments S4-5
ASIA grade B
Incomplete
Sensory but not motor function preserved below neurological level and extending through sacral segments S4-5
ASIA grade C
Incomplete
motor function preserved below the neurological level; majority of key muscles have grade < 3
ASIA grade D
Incomplete
Motor function preserved below the neurological level; majority of key muscles have a grade > 3
ASIA grade E
normal motor and sensory function
Definition of tetraplegia/quadraplegia
Partial or total loss of use of all 4 limbs and the trunk
Definition of paraplegia
Partial or total loss of the use of the lower limbs
What can cause tertraplegia/quadriplegia?
Cervical fractures
What can cause paraplegia?
Thoracic/lumbar fractures
Examples of partial cord syndromes
central cord syndrome
anterior cord syndrome
brown-sequard syndrome
Features of central cord syndrome
older patients (arthritic neck) hyperextension injury central cervical tracts more involved weakness of arms > legs perianal sensation and lower extremity power conserved
Features of anterior cord syndrome
Hyperflexion injury anterior compression fracture damaged anterior spinal artery fine touch and proprioception preserved profound weakness
Features of brown - sequard syndrome
Hemisection of the cord
Penetrating injuries
Paralysis of affected side (corticospinal)
Loss of proprioception and fine touch discrimination (dorsal columns)
Pain and temp loss on opposite side below lesion (spinothalamic)
Treatment of spinal cord injuries
KEY IS TO PREVENT SECONDARY INSULT
ABCD
- airway = C spine control
- breathing = ventilation + O2, concomitant chest injuries
- circulation = IV fluids, consider neurogenic shock
- disability = Assess neurological function
ATLS = advanced trauma life support
X rays
CT
MRI - if neurological deficit or children
Surgical fixation for unstable fractures
Long term management of spinal cord injury
spinal cord injury unit
OT
psychological support
urological/sexual counselling
Definition of spinal shock
A type of shock that causes a temporary reduction of or loss of reflexes following a spinal cord injury. Transient depression of the cord function below the level of the injury
Presentation of spinal shock
flaccid paralysis
areflexia (muscles overreact to stimuli)
Symptoms of neurogenic shock
hypotension
bradycardia
hypothermia
What is neurogenic shock secondary to?
Disruption of sympathetic outflow
Definition of neurogenic shock
A type of shock resulting in low BP and slowed HR which is attributed to the disruption of autonomic pathways within the spinal cord
Two types of lumbar disc prolapse
lateral disc protrusion
central disc protrusion
What position are disc prolapses usually?
Postero-lateral
What In the lumbar disc prolapse can cause cord/nerve root compression?
Annulus may tear + nucleus prolapse
Types of disc problems
Buldge (generalised) - mainly asymptomatic
Protrusion = annulus weakned but still intact
Extrusion = thought anulus but incontinuity
sequestrian = dessicated sic material free in canal
Where are cervical dis prolapses most common?
C5/6
Least common area of the spine for disc prolapses
Thoracic spine as doesn’t move as much
Most common thoracic area for disc prolapse
T11/12
Where are lumbar disc prolapses most common?
L4/5, then L5/S1, then L3/4
What is cauda equina syndrome a result of?
compression of the cauda equina
Management of cauda equina syndrome
URGENT MRI scan
emergency operation within 48 hours of onset - dissectomy
Causes of cauda equina syndrome
Central lumbar disc prolapse - COMMONEST tumours trauma - burst or chance fracture disc - spinal stenosis infection - epidural abscess iatrogenic - spinal surgery/manipulation - spinal epidural infection
Presentation of cauda equina syndrome
Sudden - injury or precipitating event Bilateral buttock and leg pain Varying dyskinesia and weakness Urinary retention +/- incontinence overflow bowel dysfunction saddle anaesthesia (perianal loss of sensation) loss of anal tone loss of anal reflex
investigation of cauda equina syndrome
MRI
if contraindicated = lumbar CT myelogram
What pathology does a positive straight leg raise test indicate?
Sciatic nerve pain
Red flags for back pain
Thoracic back pain Age < 20 or > 55 Non mechanical pain Pain worse when supine Night pain Weight loss Pain associated with systemic illness Presence of neurological signs Past medical history of cancer or HIV Immunosuppression or steriod use IV drug use Structural deformity
What does a prolapsed lumbar disc usually present with?
Clear dermatomal leg pain associated with neurological deficits
Features of a prolapsed disc
Leg pain usually worse than back
Pain often worse when sitting
Features of an L3 root compression
Sensory loss over anterior thigh
Weak quads
Reduced knee reflex
Positive femoral stretch test
Features of L4 root compression
Sensor loss over anterior aspect of knee
Weak quads
Reduced knee reflex
Positive femoral stretch test
Features of L5 root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexor of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Management of lumbar disc prolapse
Analgesia
Physio / exercises
If symptoms persistent i.e. beyond 4 - 9 weeks then consideration of MRI
What is discitis?
An infection of the intervertebral space
Presentation of discitis
Back pain
Fever / rigors / sepsis
Neurological features e.g. change in lower limb signs (if epidural abscess develops)
Causes of discitis
Bacterial (Staph A most common)
Viral
TB
Aseptic
Investigations of discitis
MRI
CT guided biopsy may be needed to guide Ax Tx
Treatment of discitis
IV Antibiotics 6 - 8 weeks
Complications of discitis
Sepsis
Epidural abscess
What % of sciatica resolves spontaneously with conservative treatment within 3 months?
90%
When would sciatica be routinely referred to spinal surgery?
Failure of conservative treatment after 4 - 6 weeks
