Spine - Prolapsed Intervertebral Disc and Spinal Stenosis Flashcards
What connects discs with vertebral bodies?
- Anterior longitudinal ligament (ALL) and posterior longitudinal ligament (PLL) connect discs with vertebral bodies
What are the layers of the intervertebral discs?
- Annulus fibrosis
- Tough outer layer, made of collagen
- Fibres run obliquely and alternately between layers
- Resist rotational movement
- Discs fail with twisting movement
- Nucleus pulposus
- Gelatinous core
- Made of mainly water (88%), with collagen and proteoglycans (very hydrophilic)
What is the function of the annulus fibrosis?
- Fibres run obliquely and alternately between layers
- Resist rotational movement
- Discs fail with twisting movement
What is the nucleus pulposus made of?
- Made of mainly water (88%), with collagen and proteoglycans (very hydrophilic)
What can happen if the annulus fibrosis tears?
Nucleus prolapse
What can nuclear prolapse cause?
Cord or spinal nerve compression
In what direction are nucleus prolapses normally?
- Prolapses are usually posterio-lateral
How do intervertebral discs change with ageing?
- Decreased water content of discs
- Disc space narrowing
- Degenerative changes on x-ray and in facet joints
- Aggravated by smoking etc
What movement do the facet joints between vertebrae allow?
- Allow mainly flexion and extension
What ligaments are present in the spine?
- Anterior longitudinal ligament (ALL)
- Along front of vertebral bodies
- Broad, strong
- Posterior longitudinal ligament (PLL)
- Along back of vertebral bodies
- Narrow, weaker
- Ligamentum flavum
- Between laminae
- Interspinous and supraspinous ligaments
- Between spinal processes
- Intertransverse ligament
- Between transverse processes
Is the ALL or PLL stronger?
ALL is broader and stronger than PLL
What are some pathological processes can occur in the spine?
- Tearing of annulus fibrosis and protrusion of nucleus
- Nerve root compression by osteophytes
- Central spinal stenosis
- Abnormal movement
- Spondylolysis
- Spondylolisthesis
Describe the presentation of nerve root pain?
- Pain in nerve route distribution (radicular)
- Limb pain worse than back pain
- Root tension signs
- Root compression signs
- Dermatomes and myotomes
Describe the investigations for nerve root pain?
- Referral after 12 weeks
- Imaging
- MRI
Describe the treatment for nerve root pain?
- Physiotherapy
- Strong analgesia
What are different kinds of disc problems?
- Bulge
- Generalised
- Common, most asymptomatic
- Protrusion
- Nucleus elongated instead of round
- Annulus weakened but still in tact
- Extrusion
- Through annulus but in continuity
- Sequestration
- Desiccated disc material free in canal
Where does cervical disc prolpase most commonly occur?
- Most commonly C5/C6
What parts of the spine are most affected by disc prolapse?
Lumbar -> cervical -> thoracic
Where do most thoracic disc prolapses occur?
- Most at T11/12
What are the 2 kinds of lumbar disc prolapse?
- Central protrusion
- Compressed cauda equina
- Lateral protrusion
- Most common
- Compressed spinal nerve root
Are central or lateral lumbar disc prolapses most common?
Lateral protrusion
What vertebrae are most commonly affected by lumbar disc prolapse?
- Usually L4/L5, then L5/S1 then L3/4
In what direction is what lumbar disc prolapse?
- Most are posterolateral
- Posterior longitudinal ligament weakest
Describe the presentation of lumbar disc prolapse?
- Central disc may give pain in both legs or may be back pain only
Describe the: sensory loss, motor weakness and reflex change due to disc prolapse at,
L5/S1
L4/5
L3/4
What is cauda equina syndrome?
Compression of cauda equina
MEDICAL EMERGENCY
Describe the aetiology of cauda equina syndrome?
- Lumbar disc prolapse
- Commonest
- Tumour
- Trauma or spinal stenosis
- Infection
- Epidural abscess
- Iatrogenic
- Spinal surgery
What is the commonest cause of cauda equina syndrome?
Lumbar disc prolapse
Describe the clinical features of cauda equina syndrome?
Injury/pain
Pain in bum & leg
Bowel/bladder dysfunction
Loss of perianal sensation
Loss of anal tone/reflex
Descrbe the investigations for cauda equina syndrome?
- Radiographic evaluation
- MRI
- If contraindicated, lumbar CT myelogram
Describe the prongnosis of cauda equina syndrome?
- Sacral nerve roots compressed, can result in permanent bladder and anal dysfunction if not treated quick
What is spondylosis?
OA of facet and disc joints with degeneration of ligaments
Describe the pathophysiology of spondylosis?
- Degenerative changes as facet joints, discs, ligaments etc
- If severe, can compress whole cord (not just nerve roots) causing myelopathy
Describe the clinical features of cervical and lumbar spondylosis?
- UMN signs in limbs
- Increased tone, brisk reflexes etc
What is spinal claudication?
Is a symptom, often caused by spinal stenosis
Distuinguish spinal claudication from vascular claudication?
- Usually bilateral
- Sensory dysesthesia
- Possible weakness
- Foot drop
- Takes several minutes to east after stopping walking
- Worse walking down hills because spinal canal becomes small in extension, better walking uphill
What are the different kinds of spinal stenosis?
-
Lateral recess stenosis
- Nerve emerging from spine compressed
- Unilateral symptoms
- Treatment
- Non-operative
- Nerve root injection
- Epidural injection
- Surgery
-
Central stenosis
- Risk factor is trefoil canal (congenital, canal shape)
- Bilateral symptoms
- Treatment
- Non-operative
- Epidural steroid injection
- Surgery
-
Foraminal stenosis
- Nerve root compressed just as emerges from spine
- Treatment
- Non-operative
- Nerve root injection
- Epidural injection
- Surgery
What is spondylolisthesis?
Is where one vertebra is translated onto the other
Describe the aetiology of spondylothesis?
- Degenerative
- Congenital
- Tumours
- Infection
- Fractures
Describe the treatment of spondylolisthesis?
- Depends on symptoms
- Conservative with lifestyle changes
- Surgery for persistent pain +/- nerve root entrapement
What is spondylolysis?
Defect in transverse process, posterior elements of vertebra separate from anterior elements
