Spine pathologies Flashcards
Curvatures of the spine
Lordosis - cervical, lumbar
Kyphosis - thoracic, sacral
Cervical vertebrace - C1
Atlas
No body, no spinner process
Has an anterior and posterior arch instead
Cervical vertebrae - C2
Axis
Has an odontoid process which projects superiorly from body
Cervical vertebrae - C7
Vertebrae prominens
First palpable spinous process
What kind of joints are intervertebral disc?
Secondary cartilagenous joints
Fibrocartilagenous
Function of intervertebral discs
Cushion the vertebral bodies from spinal stresses
Intervertebral disc components
Outer annulus fibrosis
Inner nucleus pulposus
Intervertebral disc degeneration
Degeneration occurs due to ageing
usually at L4/L5 level or L5/S1 level
Facet joints
Found between each vertebrae
At cervical level they are horizontal - allows lots of movement
At lumbar level they are vertical - allows limited movement
Motor neurones arise from anterior/posterior aspect of spinal cord
Anterior
Sensory neurones arise from anterior/posterior aspect of spinal cord
Posterior
What do anterior and posterior nerve roots join to form?
Mixed spinal nerve
Cauda equina region
Spinal cord ends at L1 where it becomes the caudal equine region
Red flags in history
constant back pain for over 6 weeks pain troublesome at night systemic upset history of cancer history of steroid use
x-ray overview
Usually normal
Most x-ray abnormalities are degenerative changes which may not be the cause of the patient’s presenting symptoms
MRI overview
Common to get false +ves
Only required if red flags in Hx present or if considering surgery
Mechanical back pain - definition
Recurrent relapsing and remitting back pain
Mechanical back pain - who gets it
Middle aged
Mechanical back pain - cause
Obesity
Poor posture
Poor lifting technique
Degenerative disc prolapse
Mechanical back pain - clinical features
Pain worse with movement
Pain worse at the end of the day
Mechanical back pain - management
Analgesia
Physio
Severe: spinal stabilisation surgery
Nerve root back pain - definition
Motor loss, sensory loss
Nerve root back pain - clinical features
Affects the leg more than the back
Unilateral pain
Paraesthesia (tingling, burning sensation)
Pain occurs when nerve is stretched
Nerve root back pain - management
Physio
Analgesia - but this is not effective as pain is neuropathic
Amitriptyline, gabapentin, pregablin
Complete spinal cord injury
No sensory or voluntary motor functions below the level of the injury
- (reflexes are unaffected as these are an involuntary motor function)
Incomplete spinal cord injury
Some sensory and motor functions are still present distal to the level of the injury
Sciatica - definition
Pain produced due to compression or irritation of the sciatic nerve
Sciatica - cause
Prolapsed disc
Degenerative disc disease
Sciatica - commonly affected areas
Lower lumbar spine
Buttocks
Thigh
Leg
Sciatica - nerve roots affected
L4
L5
S1
Sciatica - clinical features
Usually affects one side of the lower body
Pain originates in lower back
Pain radiates along the path of the sciatic nerve in a dermatomal distribution
- [thigh, leg, foot]
Pain is described as tingling or burning sensation
Pain relieved when lying down or walking
Pain worsened when standing still or sitting
Sciatica - L4 root entrapment symptoms
Pain worse in thigh region
Pain down to medial ankle
Reduced knee jerk
Sciatica - L5 root entrapment symptoms
Pain down to the dorsum of the foot
Numbness at the web between the big toe
Foot drop
Sciatica - S1 root entrapment symptoms
Pain down to plantar surface of foot
Reduced plantar flexion
- unable to raise heel off of the ground
Reduced ankle jerk reflex
Sciatica - examination
Reduced reflexes
Positive sciatic stretch test
Sciatica - investigations
MRI scan
Sciatica - management
Analgesia
Severe: Gabapentin
If pain doesn’t subside over time: surgery
Prolapsed disc - definition
AKA slipped disc.
Acute tear in the outer annulus fibrosis of an intervertebral disc which causes the inner nucleus pulposus to rupture out of its enclosed space.
The prolapsed disc material can enter the spinal canal, squashing the spinal cord or spinal nerves (sciatica)
Prolapsed disc - cause
Usually after lifting a heavy object
Falling from a height and landing on buttocks
Prolapsed disc - commonly affected areas
Cevical spine
Lumbar spine
Prolapsed disc - who gets it
Young/middle aged adults
Prolapsed disc - clinical features
Patient may be completely asymptomatic
Episodic back pain - worse on coughing
Sciatica like pain - as described elsewhere
Neck pain
Weakness
Cauda equina signs and symptoms (described elsewhere)
Prolapsed disc - investigations
CT
MRI
Prolapsed disc - management
Most settle themselves
Conservative management - bed rest, NSAIDs, muscle relaxants, physic
Surgical management - if patient isn’t improving by 3 months
Cauda equina syndrome - definition
Clinical emergency
Compression of the cauda equine nerve roots (which are located at the lumbrosacral spinal level)
If the nerve roots are compressed for a long period of time, permanent damage can be caused
Cauda equina syndrome - causes
Prolapsed disc
Spinal stenosis
Tumour
Cauda equina syndrome - clinical features
Bilateral sciatica leg pain
Loss of bladder and bowel function
- incontinence, urgency
Saddle anaesthesia (numbness around sitting area)
Cauda equina syndrome - examination
PR exam
Check reflexes
Cauda equina syndrome - investigations
Clinical diagnosis but imaging helps identify the cause
- MRI
- CT scan
- Myelogram X-ray of SC after injection of contrast
Cauda equina syndrome - management
Surgical decompression
- must treat and get pressure off the nerves as soon as possible
Spinal stenosis - definition
Narrowing of the spaces within mainly the cervical and lumbar spine.
This can put pressure on the nerves that travel through the spine
Spinal stenosis - cause
Osteoarthritis due to wear and tear via the formation of osteophytes Prolapsed discs Tumours Spinal injuries Manual workers Obese people
Spinal stenosis - clinical features
Pain, tingling, numbness
Symptoms gradually worsen over time
Difficulty walking down a hill as patient is leaning over and making the space even narrower
Spinal stenosis - Investigations
X-ray
MRI
Spinal stenosis - management
Analgesia
Physio
Steroid injections
Decompression surgery if symptoms persist
Spondylothesis - definition
The forward slip of one vertebrae over the vertebrae below it
Spondylothesis - areas of the spine commonly affected
L4, L5, S1
Spondylothesis - cause
Physical activity
Developmental defect
Recurrent stress fracture
Spondylothesis - who gets it
Adolescents
Obesity
Spondylothesis - clinical features
Lower back pain - especially after exercise
Waddeling gait
Spondylothesis - investigations
X-ray
Spondylothesis - management
Rest
Scoliosis - definition
Sideways curvature of the spine due to spinous processes drifting off to the side
Scoliosis - cause
Cerebral palsy
Muscular dystrophy
Idiopathic
Scoliosis - who gets it
Adolescents
Females commonly affected
Scoliosis - clinical features
Uneven shoulder height and hip height
Scoliosis - investigations
X-ray
Scoliosis - management
If mild; leave it
If severe; surgery
Spinal osteoarthritis (spondylosis)
Osteophytes can impinge on exiting nerve roots and it can result in sciatica
Spinal osteoarthritis (spondylosis) - cause
Disc degeneration
Wear and tear due to old age
Spinal osteoarthritis (spondylosis) - clinical features
slow onset stiffness and back pain
Pain may radiate to shoulders and occiput
Spinal osteoarthritis (spondylosis) - management
Physio
Analgesia
Cervical spine fracture - definition
High C-spine fractures may be fatal (especially if above C3 level)
Cervical spine fracture - cause
Usually high energy injury
Cervical spine fracture - risks
May be missed in an unconscious patient which could result in spinal cord injury
Must put unconscious patient in a C-spine collar and perform X-ray to check for C-spine injury to be safe
Cervical spine fracture - investigations
X-ray (3 views are required)
- AP view, lateral view, peg open mouth view
Cervical spine fracture - management
Stable: firm cervical collar
Unstable: immobilisation in a halo vest (external fixator)
Thoraco lumbar spine fracture - cause
Young: High energy injury
Old: Low energy injury (osteoporotic wedge fracture)
Thoraco lumbar spine fracture - clinical features
Back pain that is worsened with movement
Possible brain injury
Thoraco lumbar spine fracture - investigations
X-ray
Thoraco lumbar spine fracture - management
Stable, thoracic - brace
Stable, lumbar - plaster jacket
Unstable thoracic/lumbar - surgery
Crush fracture - definition
Vertebral compression fracture
Crush fracture - cause
Osteoporosis
Crush fracture - clinical features
Spine curves so height of patient decreases
Crush fracture - management
Usually conservative: analgesics
Chance fracture - definition
seatbelt fracture, from a seatbelt in a car crash
Chance fracture - investigations
X-ray
MRI
CT
X-rays
Show some fractures
Can you see ligaments on X-rays?
No
- but if vertebral alignment is normal this implies intact ligaments and stable spine
Can you see intervertebral discs on x-ray?
No
Can you see spinal cord on x-ray?
No
What is CT scan used for in MSK conditions?
To look for fractures the x-ray has missed
Shows intervertebral discs
Investigation of choice for viewing disc prolapse? (2)
CT scan
MRI scan
What is the best mode of imaging to view soft tissue disorders?
MRI scan
