The Lumbar Spine and Neck

Question 1

What are the red flags of back pain?

Answer 1

Age under 20 or over 60
Thoracic pain
Previous carcinoma
Immunocompromise
Feeling unwell
Weight loss
Neuro symptoms
Structural spinal deformity
Bilateral leg pain
Pain at night

Question 2

What are the yellow flags?

Answer 2

Low mood
High pain levelds
Belief that activity is harmful
Low educational level
Obesity
Problem with claim?compensation
Job dissatisfaction
Light duties not available at work
Lifting at work

Question 3

What are potential causes of mechanical back pain?

Answer 3

Obesity
Poor posture
poor lifting technique
Lack of physical activity
Depression
Degenerative disc prolapse 
Facet OA or Sponylosis

Question 4

What is spondylosis

Answer 4

When intervertebral discs lose water content with age resulting in less cushioninf and increases pressure on facet joints leading to secondary OA

Question 5

When does an acute disc tear classically occur

Answer 5

after lifting a heavy object

Question 6

What is characteristic of discogenic pain

Answer 6

worse on coughing

Question 7

What is sciatica

Answer 7

If a disc tear occurs the nucleus pulposis may herniat and press on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution and a loss of power in a myotomal distribution

Question 8

Where is the most common site for discs to impinge on nerve roots

Answer 8

L4, L5 and S1 - the nerve roots of the sciatic nerve- hence the name sciatica

Question 9

What is the pain like in sciatica

Answer 9

Neuralgic burning or tingling pain radiating down the bacl of the thigh below the knee (note back pain may radiate down legs but not below the knee)

Question 10

What nerve root will be entrapped by a L3/L4 disc prolapse

Answer 10

L4 - usually the nerve root below unless very lateral prolapse

Question 11

What are the signs of an L4 root entrapment

Answer 11

Pain down to MEDIAL ANKLE
Loss of quadriceps power
Reduced knee jerk

Question 12

What are the signs of an L5 root entrapment

Answer 12

Pain down to DORSUM of foot

Reduced power Extensor hallicus longus and tibialis anterior

Question 13

What are the signs of S1 entrapment

Answer 13

Pain to SOLE of foot
Reduces power plantarflexion
Reduced ankle jerks

Question 14

What is spinal stenosis

Answer 14

Varies pathologies causes the lumbar spinal canal to reduce in size leaving less room for the cauda equine and resulting in multiple nerve roots being compressed

Question 15

What can cause spinal stenosis

Answer 15

Sponylosis
Bulging discs
Bulging ligamentum flavum
Osteophytes

Question 16

What is the characterisitcs of spinal stenosi

Answer 16

Claudication (pain in legs on walking)
Burning pain not cramping
Pain is less when walking uphill

typically aged over 60

Question 17

What is cauda equine syndrome?

Answer 17

A very large central prolapse disc can compress all the nerve roots of the cauda equina resulting in a specific clinical syndrome

Question 18

Why is cauda equina syndrome a surgical emergency

Answer 18

affected nerve roots include the sacral nerve (s4 and s5) roots controlling defication and urination - can result in permanent nerve damage if untreated and patient may require colostomy and urinary diversion

Question 19

What are the symptoms of cauda equina?

Answer 19

Bilateral leg pain
Parasthesisa or numbness of the saddle region and perineum
Faecal incontinence and constipation
Urinary retention or incontinence

Question 20

What are the classic symptoms of cervical spondylosis

Answer 20

Slow onset stiffness and pain in neck

Radiate to shoulders and occiput

Question 21

What do patients complain of is they have a nerve root compression in the cervical spine

Answer 21

Shooting pain down a dermatomal distribution with weakness and loss of reflexes

Question 22

Which nerve root is typically affected in a cercial disc prolaspe

Answer 22

the lower nerve root ie C6/7 will impinge nerve root C7

Question 23

In which conditions can atraumatic spine instability occur

Answer 23

Down syndrome

Rheumatoid arthritis

Question 24

what is characteristic of disc pain

Answer 24

worse on coughing

Question 25

treatment of an acute disc tear

Answer 25

analgesia and physio

takes about 2-3 months to settle

Question 26

outline the treatment options of sciatica

Answer 26

1st line is analgesia, mobilise (but no heavy lifting) ad physio
gabapentin can be used in leg pain very severe

usually recover spontaneously in around 3 months

occasionally need surgery - discectomy

Question 27

what are the indications for surgery in sciatica

Answer 27

pain not resolving with conservative management + localising signs suggesting a specific nerve root + positive MRI corresponding with this

contraindications to discetomy include - evidence of secondary gain or psychological dysfunction

Question 28

what are the key examinations to perfomr in sciatica type pain

Answer 28

straight leg raise - pain in leg
bragers test - dorsiflexion in straight leg raise increases pain

also do full lower limb neuro spine and hip exam

Question 29

describe the difference between spinal stenosis symptoms and peripheral vascular disease

Answer 29

in spinal stenosis:

• claudication in inconsistent
• pain is burning
• in in less walking up hill
• pulses are preserved

Question 30

how is spinal stenosis managed

Answer 30

initially conservatively with physio weight loss and analgesia

if fails to respond or there is MRI evidence of stenosis, surgical decompression may be performed

Question 31

how should you manage a patient presenting with symptoms of cauda equine

Answer 31

must perform PR examination
urgent MRI scan
urgent referral to neurosurgery for discetomy

Question 32

who is at risk of atraumatic cervical spine instability (and therefore atlanto-axial instability/subluxation)

Answer 32

rheumatoid arthritis
Down’s syndrome

be careful if getting a GA as airway manoeuvres may precipitate

screen with flexion extension x rays