The Spine

Question 1

Describe the vertebral column

Answer 1

Vertebral column:

33 vertebrae organized in 5 sections:
7 cervical
12 thoracic
5 lumbar
5 sacral (fused)
4 coccygeal (fused)

4 curves of the healthy spine
Helps maintain posture & balance

Question 2

Describe the atypical vertebra

Answer 2

Atypical vertebra

C1 + C2 Atlas & axis
Allow head rotation

Vertebra prominens (C7)

No foramena transeverse process (veretbral artery)

Question 3

What are the two types of joint in the spine?

Answer 3

Fibrocartilaginous (secondary) Joints- These are the intervertebral discs
Facet joints

Question 4

Describe facet joints

Answer 4

These are synovial plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each spinal motion segment.

Question 5

What is spondylosis?

Answer 5

Basically osteoarthritis in the intervertebral discs which lose water content with ageing.

Question 6

Why is MRI not necessarily diagnostic with back pain and spondylosis?

Answer 6

60% asymptomatic people over 45 years old have bulging discs on MRI. Not all of these have symptoms!

Question 7

Motor neurons originate ____1____– bodies in anterior grey horn, sensory neurons originate___2____ – bodies in dorsal root ganglion

Answer 7

1) anteriorly (ventral)

2) dorsally (posterior)

Question 8

Where does the spinal cord end?

Answer 8

L1

Question 9

What is the cauda equina?

Answer 9

Bundle of spinal nerve rootlets at the end of the spinal cord

Question 10

What can disc prolapse cause? What other things can cause this?

Answer 10

Nerve root compression

compressed by osteophytes and hypertrophied ligaments in OA – known as Spinal Stenosis (neurogenic claudication)

Question 11

Explain what nerve root compression causes

Answer 11

Nerve root compression causes a radiculopathy resulting in pain down the sensory distribution of the nerve root (dermatome), which in the lower leg is known as Sciatica. Also weakness in any muscle supplied (myotome) and reduced or absent reflexes (LMN signs).

Question 12

Describe the erector spinal muscles

Answer 12

Group of 3 muscles
Iliocostalis
Longissimus thoracis
Spinalis thoracis
3 columns  each running parallel on either outer side of the Vertebra and extending from the lower back of the skull all the way down to the Pelvis.

Question 13

What is scoliosis?

Answer 13

Complex 3D deformity involving sideways curvature of the spine

Question 14

Causes of scoliosis?

Answer 14

May be secondary to a condition e.g. NM disease, birth defects, injury or infection.
Can be idiopathic

Question 15

Presentation of scoliosis?

Answer 15

Typically the patient or someone else notices rib asymmetry

Idiopathic is usually pain free and occurs in adolescents

Question 16

Treatment of scoliosis? Indications for surgery?

Answer 16

All about charting people over time to check they don’t develop a respiratory problem etc. not everyone needs surgery even if they are deformed.
Sometimes it corrects itself
Indications for surgery: High likelihood of curve progression, cosmetically unacceptable as an adult, secondary condition that needs treatment, breathing difficulties.

Question 17

Causes of kyphosis?

Answer 17

Osteoporotic collapse
Congential
Post infectious kyphosis

Question 18

Describe acute disc tear?

Answer 18

An acute tear can occur in the outer annulus fibrosis of an intervertebral disc which classically happens after lifting a heavy object (eg lawnmower). The periphery of the disc is richly innervated and pain can be severe.

Pain is characteristically worse on coughing (which increases disc pressure).

Symptoms usually resolve but can take 2‐3 months to settle.

Analgesia and physiotherapy are the mainstay of treatment

Question 19

Explain what sciatica is?

Answer 19

Disc material impinges on an exciting nerve root and this usually occurs low in the spine with L4,5 and S1 which contribute to the sciatic nerve (hence sciatica). Pain is felt down the back of thigh and below the knee. (Common mistake is to suspect sciatica with pain in gluteal region but that is likely radiated mechanical pain from the back).

Question 20

What is the difference between neurogenic claudication pain and vascular claudication pain?

Answer 20

the claudication distance is inconsistent
the pain is burning (rather than cramping)
pain is less walking uphill (spine flexion creates more space for the cauda equina)
pedal pulses are preserved

Question 21

Any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is …

Answer 21

Cauda equina syndrome until proven otherwise

Question 22

Describe mechanical back pain?

Answer 22

Most common type of back pain. It is relapsing and remitting with no neurological symptoms and is relieved by rest. No red flags. Treatment is analgesia and physio.

Question 23

What causes cauda equina syndrome?

Answer 23

A very large central disc prolapse that compresses all nerve roots of the cauda equina.

Question 24

Explain why cauda equina syndrome is a medical emergency?

Answer 24

Nerve roots of the cauda equina contribute to control of defection and urination. Prolonged compression can result in permanent damage so must be caught early.

Question 25

Symptoms of cauda equina syndrome?

Answer 25

Bilateral leg pain, paraesthesia, numbness, saddle anaesthesia, altered urinary function (typically urinary retention but incontinence can occur). Faecal incontinence and constipation can also occur. Need urgent MRI to determine level or prolapse and urgent diseconomy is required once confirmed diagnosis.

Question 26

What are 11 back pain red flags?

Answer 26

1) age under 20
2) New presentation in over 60
3) non-mechanical constant pain that isn’t better lying down
4) history of cancer- particularly breast, renal or lung
5) history of steroids
6) genreal malaise, fever, unexplained weight loss
7) structural deformity
8) Saddle anaesthsia/ paraesthesia
9) Loss of bowel or bladder control
10) Haematuria
11) Severe pain longer than 6 weeks

Question 27

Mimickers of Back Problems?

Answer 27

AAA, retroperitoneal tumours, pancreatitis, spinal infection