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Msk > The Lumbar Spine And Associated Disorders > Flashcards

The Lumbar Spine And Associated Disorders Flashcards

1
Q

How many vertebrae are there?

A 
33
7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal
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2
Q

Which regions of the vertebral column are mobile?

A 
• Mobile – Cervical and Lumbar 
• Relatively Immobile – Thoracic 
• Fused Vertebrae
• 9 vertebrae fused to give 2 innominate structures
– Sacrum (fusion of 5 vertebrae)
– Coccyx (fusion of 4 vertebrae)
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3
Q

What are the functions of the vertebral column?

A
  • Central bony pillar of the body.
  • Supports the skull, pelvis, upper limbs and the thoracic cage.
  • Protection of the spinal cord and the cauda equina
  • Movement - Highly flexible structure of bones, intervertebral discs and ligaments
  • Haemopoiesis – red marrow
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4
Q

Describe teh structure of a lumbar vertebra

A

General characteristics:
• Kidney shaped vertebral body
•Vertebral arch posteriorly
•Vertebral foramen: contains conus, cauda equina and meninges

Vertebral arch: Gives rise to 7 processes 
•x1 Spinous Process 
•x2 Transverse Process 
•x2 Superior Articular Process 
•X2 Inferior Articular Process
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5
Q

What is a vertebral body?

A
  • Largest part of the vertebra –
  • 10% Cortical Bone
  • 90% Cancellous Bone
  • Usually the main weight bearing Greater Compressive forces distally part of the vertebra
  • End Plates – Superior and Inferior Articular surfaces covered with hyaline cartilage
  • Linked to adjacent vertebral bodies by intervertebral discs
  • Size Vertebra increases from superior to inferior?
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6
Q

What are vertebral processes

A
  • 1 spinous process,
  • 2 transverse processes (left and right)
  • 2 superior articular processes (facets) interlock with the vertebra above
  • 2 inferior articular processes (not shown) interlock with the vertebra below.
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7
Q

What is the vertebral arch?

A
  • Lamina connects transverse process to spinous process
  • Pedicle connects transverse process to body
  • Pedicles longer and larger bigger intervertebral foramen
  • Lamina + pedicle = vertebral arch
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8
Q

What is a facet joint?

A

• Lined with hyaline cartilage
• Paired
• Spinal nerves emerge through intervertebral foramina
• Orientated in a sagittal plane
• Interlocking design
– Prevents anterior displacement of vertebrae
– Orientation determines amount of flexion and rotation permitted

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9
Q

What are the movements of the lumbar spine?

A

Flexion and extension
Lateral flexion
Rotation

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10
Q

What are the types of joints in the spine?

A
  • Fibrous – (ligaments) non- mobile
  • Cartilaginous – Partially mobile
  • Synovial Joints
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11
Q

What are intervertebral discs?

A

• Account for 25% of the length of the vertebral column
• 70% Water, 20% Collagen, 10% Proteglycans (proteoglycans keep water in the disc)
• Lose height with age (proteoglycans lose ability to retain water)
• Slightly wedge-shaped posteriorly
• Consist of two regions:
– nucleus pulposus (central)
– annulus fibrosus (peripheral)

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12
Q

What is an annulus fibrosus?

A
  • Highly complex design
  • Made from lamellae of annular bands in varying orientations
  • Type 1collagen
  • Avascular and Aneural
  • Surrounds nucleus pulposus
  • Is the major ‘shock absorber’
  • Highly resilient under compression - stronger than the vertebral body
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13
Q

What is the nucleus pulposus?

A
  • Remnant of notochord
  • Gelatinous, Type 2 Collgen
  • High osmotic pressure
  • Disc Height changes throughout day
  • Disc Height changes with age
  • Surrounded entirely by annulus fibrosus
  • Centrally located in the infant
  • Located more posteriorly in the adult
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14
Q

What is the function of the ligaments of the vertebral column

A
  • Provide stability
  • Major ligaments: anterior longitudinal and posterior longitudinal ligament (anterior and posterior to vertebral bodies)
  • Anterior is stronger than posterior
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15
Q

What is the anterior longitudinal ligament?

A
  • Anterior tubercle of atlas to sacrum
  • Blends with periosteum of vertebral bodies
  • Mobile over intervertebral discs
  • Prevents hyperextension

Becomes taught when leaning back
Prevents extension

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16
Q

What is the posterior longitudinal ligament?

A
  • Body of axis to sacral canal
  • Continues superior to axis as ‘tectorial membrane’
  • Weaker than ALL
  • Prevents hyperflexion
  • Reinforces annulus centrally leading to paracentral disc prolapses

Becomes taught when leaning forwards

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17
Q

What are the ligamentum flavum

A

• Yellow in colour: elastin elastic fibres
• Between laminae of adjacent vertebrae
• Stretched during flexion of the spine
See slide for position

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18
Q

What are interspinous ligaments?

A
  • Relatively weak sheets of fibrous tissue
  • Unite spinous processes along adjacent borders
  • Well developed only in the lumbar region (stability in flexion)
  • Fuse with supraspinous ligaments

See slide for positioning

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19
Q

What are supraspinous ligaments

A 
• Tips of adjacent spinous processes 
 • Strong bands of white fibrous tissue 
• Lax in extension 
• Tight in flexion (mechanical support for vertebral column)
See slide for positioning
20
Q

Where is the body weight distributed through the spine?

A

• Weight 80% vertebral bodies and 20% facet joints
• Older disc dehydration – greater forces through the facet joints
As you get older
More forcee through facet joints - 35% not 20%

21
Q

What are the sacrum and coccyx?

A
  • Sacrum consists of 5 fused vertebrae
  • Articulates with L5 superiorly , ilium laterally, and coccyx inferiorly
  • Learn the osteology yourselves (ADD to this)
  • Coccyx consists of 4 fused vertebrae
  • Easily fractured during falls
  • Remnant of ‘tail’
22
Q

What are lordosis and kyphosis

A 
Kyphosis = concave anteriorly
Lordosis = convex anterirly
23
Q

Describe the curvature of the vertebral column

A 
Cervical - lordosis
Thoracic - kyphosis
Lumbar - lordosis
As ray - kyphosis
Coccyx - kyphosis
24
Q

How des the vertebral column develop in the fetus?

A
  • Flexed in a single curvature
  • C-shaped
  • Concave anteriorly = kyphosis
  • This curvature is known as the Primary Curvature
  • Primary curvature is retained throughout life in Thoracic, Sacral and Coccygeal regions
25
Q

How does the vertebral column develop from foetus to young adult?

A

• The primary curvature is remodelled to add two
SECONDARY CURVATURES
• The cervical spine develops the first posterior concavity (cervical lordosis) when young child begins to lift its head
• The lumbar spine loses it’s primary kyphosis during crawling
• When the child begins to stand- up and walk, lumbar lordosis develops.
• Lumbar lordosis is the second secondary curvature

26
Q

Describe the vertebral column in a young adult

A
  • 4 distinct curvatures
  • Sinusoidal profile - confers great flexibility and resilience
  • 2 kyphoses (anterior flexions): thoracic and sacrococcygeal
  • Kyphoses are continuations of the primary curvature of the foetus
  • 2 lordoses (posterior flexions): cervical and lumbar
  • Lordoses are SECONDARY CUVATURES (developmental)
27
Q

Describe the vertebral column non old age

A
  • Secondary curvatures start to disappear
  • Loss of disc and osteoporotic fractures
  • Continuous primary curvature is re-established
  • ‘Senile kyphosis’
28
Q

How does the vertebral column change during pregnancy

A

Exaggeration of the lumbar lordosis

  • supports the weight of the fetus
  • head above pelvis
29
Q

How does the weight of the body pass through the vertebral column and how are the sacral vertebrae adapted to this?

A
  • The weight of the body is projected into lower limbs about a line that passes centrally through the natural curvatures of the vertebral column
  • Sacral vertebrae: fused, widened & concave anteriorly to transmit weight of the body through pelvis to legs
Centre of gravity 
• Passes through vertebral column at:
– C1 & C2
– C7 & T1
– T12 & L1
– L5 & S1
• ‘Weak points’ of vertebral column
• Curves need to be balanced to aid walking and stop us falling
30
Q

What is mechanical back pain?

A
  • Pain when the spine is loaded (sitting, standing, not lying)
  • Worse with exercise relieved by rest
  • Intermittent
  • Often triggered by innocuous activity
  • Predisposition overweight, unhealthy lifestyle, deconditioned core muscles
31
Q

How can lumbar back pain get confused with age related changes ?

A
  • Nucleus pulposus dehydrates with age
  • Loss of disc height disc – DISC BULGE
  • Load stresses on the IV disc alter → reactive ‘marginal osteophytosis’ adjacent to affected endplates SYNDESMOPHYTES
  • Increased load stress on the facet joints FACET JOINT OSTEOARTHRITIS(innervated by meningeal branch of spinal nerve → pain)
  • Decreased size of intervertebral and vertebral foramen and compression of cauda equina or exiting spinal nerve roots
32
Q

Describe the natural ageing of the spine

A

See slide for images

33
Q

What is prolapse in terms of a slipped disc?

A

• Prolapse: protrusion of the nucleus
pulposus with slight impingement
into the spinal canal (contained)

34
Q

What is extrusion in terms of a slipped disc?

A

• Extrusion: nucleus pulposus
breaks through annulus fibrosus,
but remains within the disc space.

35
Q

What is sequestration in terms of a slipped disc?

A

• Sequestration: nucleus pulposus
breaks through annulus fibrosus
and separates from the main body
of the disc in the spinal canal.

36
Q

Where does a slipped disc usually occur?

A
  • Most commonly occurs at L4/5 or L5/S1

* Usually herniates posterolaterally, causing compression of spinal nerve roots

37
Q

Name types of disc prolapse?

A
  • Paracentral – 96%
  • Far Lateral – 2%
  • Canal Filling – CES – 2%
38
Q

What is sciatica?

A

• Sciatica is compression of the nerve roots which contribute to the sciatic nerve

39
Q

Which nerve roots contribute towards the sciatic nerve?

A

L4, L5, s1, S2, S3

40
Q

Name some types of sciatica

A

• Based on Dermatomes

• L4 Sciatica
Anterior thigh, Anterior knee, medial shin

  • L5 Sciatica
  • Lateral Thigh, lateral calf, dorsum of foot
  • S1 Sciatica
  • Posterior Thigh, Posterior, Calf, Heel, Sole of Foot
41
Q

Which nerve root is compressed in sciatica

A

See slide for diagram

42
Q

In whomst does disc prolapse occur most frequently

A
  • Occurs in 30 to 50 year olds

* Natural History = 90% resolve by 3 months

43
Q

What is cauda equina syndrome

A
  • Canal filling disc compressing the Lumbar and Sacral Nerve roots
  • Occurs in 30 – 50 year olds
  • 2% all PIDs
  • Bilateral Sciatica
  • Perianal Numbness
  • Painless Retention of Urine
  • Urinary/ Faecal Incontinence
  • Need to Treat within 48 Hours of Sphincter Symptoms to be in good prognostic group
  • Intermittent Self Catherisation
  • DRE
  • Sexual Dysfunction
44
Q

What is lumbar canal stenosis

A

See notes

• 70% stay the same • 15% progressive worse • 15% Better

45
Q

What is claudication

A

Pain in legs when walks

• Neurogenic • Vascular

46
Q

What is spondylolisthesis and what causes it?

A
  • A slip of the one vertebra on another

* Abnormality in Vertebral Arch

47
Q

Name types of spondylolisthesis

A
  • Dysplastic – Congenital - Abnormality in facet joint
  • Isthmic – Developmental
  • Abnormality in pars interarticularis
  • Back Pain in Adolescence
  • Gymnasts and fast bowlers

• Degenerative

  • Middle aged ladies
  • Facet Joint Arthritis
  • Iatrogenic – remove too much lamina and facet joint
  • Pathological - tumour affects the neural arch

Msk (15 decks)

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