Spine - Prolapsed Intervertebral Disc and Spinal Stenosis

Question 1

What connects discs with vertebral bodies?

Answer 1

• Anterior longitudinal ligament (ALL) and posterior longitudinal ligament (PLL) connect discs with vertebral bodies

Question 2

What are the layers of the intervertebral discs?

Answer 2

• 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)

Question 3

What is the function of the annulus fibrosis?

Answer 3

• Fibres run obliquely and alternately between layers
  
  • Resist rotational movement
  • Discs fail with twisting movement

Question 4

What is the nucleus pulposus made of?

Answer 4

• Made of mainly water (88%), with collagen and proteoglycans (very hydrophilic)

Question 5

What can happen if the annulus fibrosis tears?

Answer 5

Nucleus prolapse

Question 6

What can nuclear prolapse cause?

Answer 6

Cord or spinal nerve compression

Question 7

In what direction are nucleus prolapses normally?

Answer 7

• Prolapses are usually posterio-lateral

Question 8

How do intervertebral discs change with ageing?

Answer 8

• Decreased water content of discs
• Disc space narrowing
• Degenerative changes on x-ray and in facet joints
  
  • Aggravated by smoking etc

Question 9

What movement do the facet joints between vertebrae allow?

Answer 9

• Allow mainly flexion and extension

Question 10

What ligaments are present in the spine?

Answer 10

• 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

Question 11

Is the ALL or PLL stronger?

Answer 11

ALL is broader and stronger than PLL

Question 12

What are some pathological processes can occur in the spine?

Answer 12

• Tearing of annulus fibrosis and protrusion of nucleus
• Nerve root compression by osteophytes
• Central spinal stenosis
• Abnormal movement
  
  • Spondylolysis
  • Spondylolisthesis

Question 13

Describe the presentation of nerve root pain?

Answer 13

• Pain in nerve route distribution (radicular)
• Limb pain worse than back pain
• Root tension signs
• Root compression signs
• Dermatomes and myotomes

Question 14

Describe the investigations for nerve root pain?

Answer 14

• Referral after 12 weeks
• Imaging
  
  • MRI

Question 15

Describe the treatment for nerve root pain?

Answer 15

• Physiotherapy
• Strong analgesia

Question 16

What are different kinds of disc problems?

Answer 16

• 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

Question 17

Where does cervical disc prolpase most commonly occur?

Answer 17

• Most commonly C5/C6

Question 18

What parts of the spine are most affected by disc prolapse?

Answer 18

Lumbar -> cervical -> thoracic

Question 19

Where do most thoracic disc prolapses occur?

Answer 19

• Most at T11/12

Question 20

What are the 2 kinds of lumbar disc prolapse?

Answer 20

• Central protrusion
  
  • Compressed cauda equina
• Lateral protrusion
  
  • Most common
  • Compressed spinal nerve root

Question 21

Are central or lateral lumbar disc prolapses most common?

Answer 21

Lateral protrusion

Question 22

What vertebrae are most commonly affected by lumbar disc prolapse?

Answer 22

• Usually L4/L5, then L5/S1 then L3/4

Question 23

In what direction is what lumbar disc prolapse?

Answer 23

• Most are posterolateral
  
  • Posterior longitudinal ligament weakest

Question 24

Describe the presentation of lumbar disc prolapse?

Answer 24

• Central disc may give pain in both legs or may be back pain only

Question 25

Describe the: sensory loss, motor weakness and reflex change due to disc prolapse at, L5/S1 L4/5 L3/4

Answer 25

Question 26

What is cauda equina syndrome?

Answer 26

Compression of cauda equina MEDICAL EMERGENCY

Question 27

Describe the aetiology of cauda equina syndrome?

Answer 27

* Lumbar disc prolapse * Commonest * Tumour * Trauma or spinal stenosis * Infection * Epidural abscess * Iatrogenic * Spinal surgery

Question 28

What is the commonest cause of cauda equina syndrome?

Answer 28

Lumbar disc prolapse

Question 29

Describe the clinical features of cauda equina syndrome?

Answer 29

Injury/pain Pain in bum & leg Bowel/bladder dysfunction Loss of perianal sensation Loss of anal tone/reflex

Question 30

Descrbe the investigations for cauda equina syndrome?

Answer 30

* Radiographic evaluation * MRI * If contraindicated, lumbar CT myelogram

Question 31

Describe the prongnosis of cauda equina syndrome?

Answer 31

* Sacral nerve roots compressed, can result in permanent bladder and anal dysfunction if not treated quick

Question 32

What is spondylosis?

Answer 32

OA of facet and disc joints with degeneration of ligaments

Question 33

Describe the pathophysiology of spondylosis?

Answer 33

* Degenerative changes as facet joints, discs, ligaments etc * If severe, can compress whole cord (not just nerve roots) causing myelopathy

Question 34

Describe the clinical features of cervical and lumbar spondylosis?

Answer 34

* UMN signs in limbs * Increased tone, brisk reflexes etc

Question 35

What is spinal claudication?

Answer 35

Is a symptom, often caused by spinal stenosis

Question 36

Distuinguish spinal claudication from vascular claudication?

Answer 36

* 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

Question 37

What are the different kinds of spinal stenosis?

Answer 37

* **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

Question 38

What is spondylolisthesis?

Answer 38

Is where one vertebra is translated onto the other

Question 39

Describe the aetiology of spondylothesis?

Answer 39

* Degenerative * Congenital * Tumours * Infection * Fractures

Question 40

Describe the treatment of spondylolisthesis?

Answer 40

* Depends on symptoms * Conservative with lifestyle changes * Surgery for persistent pain +/- nerve root entrapement

Question 41

What is spondylolysis?

Answer 41

Defect in transverse process, posterior elements of vertebra separate from anterior elements