The Back

Question 1

Describe the relationship of the nerve root to the vertebra in the cervical spine

Answer 1

Nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra)

7 Cervical vertebrae, 8 cervical nerve roots

Question 2

Where does the spnal cord terminate?

Answer 2

Conus medullaris (L1)

Question 3

Describe th relationship of the nerve root to the vertebra in the lumbar spine

Answer 3

Individual nerve roots exit below pedicle of vertebra (i.e. L4 nerve root exits below L4 pedicle)

Question 4

Define spinal stenosis

Answer 4

Narrowing of spinal canal less than 10mm

Question 5

What is the gold standard for investigating spinal stenosis?

Answer 5

CT myelogram

Question 6

How is spinal stenosis managed?

Answer 6

Non-operative: vigorous physiotherapy (flexion exercises, stretch/strength exercises), NSAIDs, lumbar epidural steroids

Operative - decompression surgery if conservative methods failed for more than 6 months

Question 7

How is mechanical back pain defined?

Answer 7

Back pain not due to prolapsed disc or any other clearly defined pathology

Question 8

At which level are lumbar disc herniations most common?

Answer 8

L5/S1
then
L4/L5
then
L3/L4

Question 9

How is a lumbar disc herniation investigated?

Answer 9

MRI

Question 10

How is a lumbar disc herniation managed? (2)

Answer 10

1. Symptomatic - physiotherapy, NSAIDs (90% resolve in 3 months)
2. Surgical discectomy reserved for progressive neurological deficit, failure of symptoms to resolve within 3 months or cauda equina syndrome due to central disc herniation

Question 11

When is surgical discectomy for a lumbar disc herniation considered? (3)

Answer 11

1. Progressive neurological deficit
2. Failure of symptoms to resolve within 3 months
3. Cauda equina syndrome due to central disc herniation

Question 12

What is the distinction between spondylolysis and spondylolisthesis?

Answer 12

Spondylolysis: defect in the pars interarticularis (inferior articular process) with no movement of the vertebral bodies

Spondylolisthesis: defect in pars interarticularis causing a forward slip of one vertebra on another - usually at L5-S1, less commonly at L4-5

Question 13

How does spondylolisthesis clinically present?

Answer 13

Lower back pain radiating to buttocks

Question 14

Which vertebrae are most commonly affected in spondylolisthesis?

Answer 14

L5/S1. Followed by L4/L5

Question 15

When is surgical intervention considered for spondylolisthesis?

Answer 15

When slippage is considered to be at 50-75% (Class III)

Question 16

What is a “Hangman’s fracture?”

Answer 16

Fracture of the C2 pars interarticularis - stable

Question 17

What is a Burst fracture?

Answer 17

Type of vertebral fracture - extreme axial force causes vertebra to fracture in several places

Question 18

Which columns are involved in a seatbelt fracture?

Answer 18

All 3 columns

Question 19

What are the components in each of the 3 columns of the vertebrae (acc. to Denis 3 column model)?

Answer 19

Anterior: Anterior longitudinal ligament, anterior half of vertebral body, anterior annular fibrosis

Middle: Posterior half of vertebral body, posterior annulus/disc

Posterior: spinous process, laminae, facets

Question 20

Which column is usually involved in a compression/wedge fracture, and when do these commonly occur?

Answer 20

Compression force causes anterior column to collapse - stable unless other columns affected

commonly found in osteoporosis