Week 12 - spinal disorders Flashcards
1
Q
What is ankylosing spondylitis? (LO1)
A
Inflammatory arthritis of the sacroiliiac joints and axial skeleton characterised by ankylosing and enthesitis. This comes under a larger group of arthritis’ called seronegative spondyloarthropathies (SpA).
2
Q
What is enthesitis? (LO1)
A
Inflammation at tendon insertions.
3
Q
Describe the epidemiology of ankylosing spondylitis. (LO1)
A
- 0.1%-1% of the population.
- Varies with prevalence of the HLA-B27 and ethnicity.
- It is more prevalent in those with positive family history of spondyloarthropathy.
- Males are 3 times more likely to have it.
- 15-35 year olds.
- Symptoms will appear before the age of 45 in the majority of people.
4
Q
Describe the pathophysiology of ankylosing spondylitis. (LO1)
A
- The result of interaction between environmental pathogens and the host immune system in genetically susceptible individuals.
- Increased faecal carriage of Klebsiella aerogenes has been reported in established AS.
- Increasing evidence that axSpA and AS are due to abnormal host response to intestinal microbiota and involvement of Th17 cells (cells with a key role in mucosal immunity).
- This reaction leads to the production of various inflammatory cytokines, e.g. IL-12, IL-23, IL-17 and TNF-α.
5
Q
List the genes that increase susceptibility to ankylosing spondylitis. (LO1)
A
- HLA-B27: 95% of patients with ankylosing spondylitis are positive for this gene, an MHC class 1 molecule.
- ERAP-1: an endoplasmic reticulum protein which facilitates intracellular antigen processing and binds with its presenting MHC molecule, HLA-B27.
- IL-23 receptor.
- Molecules involved in directing Th17 cell responses, e.g. STAT13.
6
Q
Describe the musculoskeletal presentation of ankylosing spondylitis. (LO1)
A
- Prolonged morning stiffness of insidious onset, lasting >3 months.
- Bilateral sacroiliac joint tenderness (sacroiliitis).
- Inflammatory back pain - IMPROVES WITH EXERCISE, WORSENS WITH REST.
- Limited lumbar spine motion.
- Tenderness at enthesis, especially Achilles’ tendons and plantar fascia.
- Rib cage involvement: limited chest expansion.
- Possible peripheral joint arthritis, usually involving lower extremities.
7
Q
Describe the presentation of advanced ankylosing spondylitis. (LO1)
A
- Compensatory hyperextension of the neck.
- Fixed flexion of the hips.
- Compensatory flexion of the knees.
8
Q
List the non-musculoskeletal manifestions of ankylosing spondylitis. (LO1)
A
- Iritis and uveitis.
- Aortic insufficiency.
- Cardiovascular disease.
- Pulmonary fibrosis.
- Increased risk of osteoporosis.
9
Q
What two types of investigations can be carried out for ankylosing spondylitis? (LO1)
A
- Bloods.
- Radiological.
10
Q
List the blood tests that can be done to investigate ankylosing spondylitis. (LO1)
A
- FBC.
- ESR.
- CRP.
- Serological rheumatoid factor.
- Genotyping for HLA-B27.
11
Q
Describe the interpretation of blood results in a patient with ankylosing spondylitis. (LO1)
A
- FBC - showing anaemia of chronic disease.
- ESR - often elevated during active phases of the disease.
- CRP - often elevated during active phases of the disease.
- RF - negative.
- HLA-B27 genotyping - positive in 95% of patients with AS but not required for a diagnosis. May be useful where the clinician has doubts.
12
Q
List the radiological investigations that can be done to investigate ankylosing spondylitis. (LO1)
A
- X-ray - can appear normal.
- MRI - first choice.
13
Q
Describe the advantages of using MRIs to investigate ankylosing spondylitis over x-rays. (LO1)
A
- Able to detect inflammatory back disease in cases where x-rays appear normal.
- Prevents x-ray exposure to the pelvis which is particularly important in young patients.
14
Q
Describe the potential results of MRIs in patients with ankylosing spondylitis. (LO1)
A
- Sacroiliitis and bone oedema highlight ongoing inflammation.
15
Q
Despite MRIs being first choice for ankylosing spondylitis imaging, how can x-rays also be helpful? (LO1)
A
- They can help assess damage where substantial mechanical change has occurred.
- Views of the lumbar spine may show bamboo spine: squaring of vertebrae and formation of syndesmophytes (due to ossification of the longitudinal ligaments).
- At other sites: enthesitis erosions, e.g. at plantar fascia of Achilles’ tendon.
16
Q
Describe the conservative management of ankylosing spondylitis. (LO1)
A
- Physiotherapy: long-term exercise programme with the aim of maintaining normal posture and exercise activity.
- Hydrotherapy - can be beneficial.
17
Q
Describe the drug treatment side of management for ankylosing spondylitis. (LO1)
A
Initial treatment:
- NSAIDs.
Continuous therapy is needed where there is ongoing evidence of inflammation:
- NSAIDs.
- COX-1 inhibitors.
- COX-2 inhibitors.
Anti-TNFs:
- Secukinumab: anti-IL17.
- Good efficacy in treating and preventing ankylosing spondylitis progression.
18
Q
When can DMARDs (methotrexate, sulphasalazine) be used for ankylosing spondylitis? (LO1)
A
- These immunosuppressive drugs are less beneficial in ankylosing spondylitis unless there is peripheral arthritis.
19
Q
Describe the prognosis of ankylosing spondylitis. (LO1)
A
- Prognosis for any AxSpA disorder not fully understood yet.
- They can remain mild and/or episodic in many patients for many years.
- HLA-B27 positivity, persistently high CRP and high functional incapacity are markers of poor prognosis and markers of extension to ankylosing spondylitis (if not already developed).
20
Q
What are two main classifications of back pain? (LO2)
A
- Inflammatory.
- Non-inflammatory.
21
Q
List the possible causes of non-inflammatory back pain. (LO2)
A
- Mechanical/low back pain +/- sciatica.
- Osteoarthritis.
- Spinal stenosis.
- Spondylolisthesis.
- Scoliosis.
- Vertebral fracture.
22
Q
List the possible causes of inflammatory back pain. (LO2)
A
- Infection, e.g., disciitis, osteomyelitis, abscess.
- Axial spondyloarthropathies.
- Malignancy.
23
Q
List the terms commonly used when talking about back pain. (LO2)
A
- Discogenic pain.
- Degenerative disc disease.
- Lumbar disc herniation.
- Secondary to lumbar degenerative disease.
- Facet joint pain.
24
Q
List some alternative terms for sciatica. (LO2)
A
- Sciatica/lumbago.
- Radicular pain/radiculopathy.
- Pain radiating to the leg.
- Nerve root compression/irritation.
- Neurogenic claudication.
- Spinal stenosis.
25
Describe the epidemiology of mechanical back pain. (LO2)
- Low back pain causes more disability than any other conditions.
- Prevalence increases up to the 6th decade.
- Most common in Western Europe - roughly 10% of the population have back pain.
- Slightly more common in women.
26
How do we assess symptoms for back pain? (LO2)
- Symptoms.
- Assess if nerve root irritation is present.
- Nerve root irritation tests.
- Document neurological signs.
- Exclude cauda equina syndrome.
27
Describe the epidemiology of lower back pain (LBP). (LO2)
- 90% of all back pain.
- Exact causes are hard to identify.
- Onset 20-55 years.
- Poorly localised, usually lumbosacral but may radiate towards the buttocks and thighs.
- Pain worse towards end of the day.
- Patient is systemically well.
28
Describe the prognosis for mechanical back pain. (LO2)
- Good.
- 50% of patients are better within a week.
- 90% of patients are better within 6 weeks.
29
Why is physical activity recommended for back pain? (LO2)
- Rest perpetuates disability.
- May relieve venous congestion and oedema.
- Muscular activity may interfere with pain signal processing.
- Spinal movement may have a similar effect.
30
Describe the initial management of back pain. (LO2)
- Examine the patient.
- Ask them to wait 1 week.
- If not improved in a week, ask them to wait 6 weeks.
- If still not improved then further investigations required.
- Do not refer for investigations unless high risk of poor outcome.
- Imaging in specialist settings of care only if the result is likely to change management.
- Educate on how to self-manage their low back pain with or without sciatica and encourage continuation of normal activities.
- Group exercise programme.
31
What 3 types of assessments carried out if a patient with back pain isn't better after 6 weeks? (LO2)
- Biological assessment.
- Psychological assessment.
- Social assessment.
32
Describe the biological assessment of a patient with back pain lasting >6 weeks. (LO2)
- Check for nerve root problems.
- Red flags?
- Check CRP.
- Lumbar spine x-ray if relevant.
33
Describe the psychological assessment of a patient with back pain lasting >6 weeks. (LO2)
- Unjustified fears?
| - Depressed?
34
Describe the social assessment of a patient with back pain lasting >6 weeks. (LO2)
- Family relationships.
| - Work problems.
35
Describe the presentation of nerve root pain. (LO2)
- Unilateral leg pain > back pain.
- Numbness and paraesthesia.
- Nerve irritation signs.
- Motor sensory or reflex change - limited to one nerve root.
- Radiation below the knee.
36
Which nerve roots usually lead to nerve root pain? (LO2)
- 83% of prolapsed intervertebral discs will involve L5 or S1 roots.
- L5: 51%.
- S1: 22%.
- L5 AND S1: 10%.
- L3 or L4: 17% (usually in the elderly).
37
Define radiculopathy. (LO3)
Nerve root dysfunction often from mechanical compression. Inflammatory cytokines from damaged intervertebral discs also cause symptoms.
38
How many types of radiculopathy are there? Name them. (LO3)
3 types:
- Cervical radiculopathy.
- Thoracic radiculopathy.
- Lumbar radiculopathy/lumbosacral radiculopathy (sciatica).
39
Describe the epidemiology of each radiculopathy. (LO3)
Cervical radiculopathy:
- 107.3 per 100,000 in men.
- 63.5 per 100,000 in women.
- Risk factors - age (secondary to degeneration of spine).
Thoracic radiculopathy:
- Uncommon.
- Often mistaken for shingles.
Lumbar radiculopathy:
- 3-5% population.
- Men mainly affected in their 40s.
- Women affected in their 50-60s.
- Risk factors: female, white ethnicity, age, physically demanding occupations.
40
List some common causes of radiculopathies. (LO3)
- Laterally herniated disc.
- Spondylolysis.
- Spondylolisthesis.
- Age-related degeneration.
- Spinal stenosis.
- Facet joint degeneration.
- Synovial cysts.
- Infection.
- Trauma.
- Osteoporosis.
- Vertebral compression fractures.
41
List some rare causes of radiculopathies. (LO3)
- Radiation.
- Diabetes.
- Malignancy.
- Meningeal-related disease processes.
42
Describe the pathophysiology of radiculopathies. (LO3)
- Compression of a nerve root (can be sudden or gradual onset).
- Gradual onset can be due to impingement from bony osteophytes into the intervertebral foramen.
- Impingement of the nerve root can cause localised ischaemia/nerve damage (mechanical and chemical pathways).
- The chemical cascade is triggered by the nucleus pulposus.
- Disc degeneration and local ischaemia trigger the pro-inflammatory cascade, involving TNF-α, IL-6 and matrix metalloproteinases and prostaglandins.
- This leads to further sensitisation and increased pain.
43
Which nerve roots are commonly affected in cervical radiculopathy? (LO3)
C7 root is most commonly affected due to C6-C7 disc herniation.
C6 (C5-C6 herniation) and C8 (C7-T1 herniation) are also common.
44
Which nerve roots are commonly affected in lumbosacral radiculopathy? (LO3)
- L3-L4 root compression = pain radiates to anterior thigh.
- L5-S1 nerve root most commonly affected = "classical sciatica" - pain and tingling radiating down the posterior leg and into foot.
45
Describe the general presentation of radiculopathies. (LO3)
Dependent on impinged nerve roots.
- Sensory deficits/paraesthesia: burning, tingling, numbness.
- Pain described as shooting or electrical shocks.
- Reduced reflexes.
- Muscle weakness.
46
Describe the common presentation of cervical radiculopathy. (LO3)
Pain:
- Neck.
- Arm.
- Hand.
- Finger.
- May radiate along the distribution of affected nerve root.
- Rigid pain.
- Pain is worse on movement.
47
Describe the common presentation of cervical radiculopathies according to the common nerve roots affected. (LO3)
C5:
- Sensory loss of dorsal upper arm.
- Muscle weakness of the biceps, deltoid and spinati.
- Biceps reflex lost.
C6:
- Sensory loss of lateral arm.
- Muscle weakness of the brachioradialis.
- Supinator reflex lost.
C7:
- Sensory loss of dorsal arm.
- Muscle weakness of the triceps, fingers and wrist extensors.
- Triceps reflex lost.
48
Describe the common presentation of thoracic radiculopathies according to the common nerve roots affected. (LO3)
Pain in chest and torso.
49
Describe the common presentation of lumbar radiculopathies according to the common nerve roots affected. (LO3)
Sciatica.
50
List the differentials for radiculopathies. (LO3)
- Peripheral nerve entrapment syndrome.
- Shoulder pathologies.
- Shingles.
- Ankylosing spondylitis.
- Epidural abscess.
- Inflammatory arthritis.
- Inflammatory bowel disease.
- Leukaemia.
- Lumbosacral disc injuries.
- Lymphoma.
- Metastatic carcinoma.
- Multiple myeloma.
51
Describe the investigations for radiculopathies. (LO3)
Must rule out red flags.
- History.
- Physical exam - straight leg raise test (for sciatica).
- Neurological exam of upper and lower limbs.
- MRI/CT myelogram (contrast dyes) to confirm.
- If NO trauma indicated and only isolated cervical pain then no imaging required.
52
Describe the management of radiculopathies before the 6 week mark of the patient experiencing symptoms. (LO3)
Conservative treatment up to 6 weeks:
- Immobilisation.
- Anti-inflammatories.
- Physiotherapy.
- Epidural steroid injections.
- Cervical traction (benefits disputed).
53
Describe the management of radiculopathies AFTER the 6 week mark of the patient experiencing symptoms. (LO3)
Persistent symptoms after 6 weeks of conservative treatment/significant functional deficity is an indication for surgery.
- Anterior cervical decompression and fusion.
- Micro laminectomy (complete removal/partial removal).
- Posterior cervical foraminotomy/discectomy.
- Cervical disc arthroplasty.
54
Describe the prognosis of radiculopathies. (LO3)
- Typically self-limiting.
| - 75-90% of patients' symptoms improve without operations.
55
What is cauda equina syndrome? (LO4)
Compression of the nerve roots forming the cauda equina (the tail end of the spinal cord). Cauda equina syndrome is a surgical emergency, requiring urgent intervention to prevent permanent neurological deficits.
56
List the two types of cauda equina syndrome. (LO4)
- Incomplete - complaints about urinary difficulty, altered urinary sensation, loss of desire to void, hesitancy and urgency.
- Complete - definitive urinary retention with associated overflow incontinence.
57
Describe the epidemiology of cauda equina syndrome. (LO4)
- 1 person per 33,000-100,000.
| - Most commonly due to a herniated lumbar disc.
58
Describe the presentation of cauda equina syndrome (from history taking). (LO4)
- Severe back pain.
- Bilateral sciatica.
- Perianal 'saddle' paraesthesia.
- Bowel and bladder dysfunction.
- Sexual dysfunction.
- History of spinal pathology or malignancy.
- Past spinal operations.
- Occupation and functional status.
59
Describe the findings of a lower limb neurological exam as an investigation for cauda equina syndrome. (LO4)
- Hypotonia - decreased tone.
- Bilateral or unilateral weakness.
- Areflexia - absence of deep tendon reflexes.
- Abnormal sensory changes.
60
Describe the findings of a rectal exam as an investigation for cauda equina syndrome. (LO4)
- Saddle anaesthesia - reduced sensation in the area that would be in contact with a saddle if sitting on one (perineum, buttocks, anus, groin and upper thighs).
- Reduced perineal sensation.
- Reduced ANAL SPHINCTER TONE - this is a red flag.
61
Describe the findings of an abdominal exam as an investigation for cauda equina syndrome. (LO4)
The following findings are considered to be red flags for CES according to NICE guidance:
- Severe bilateral deficit of legs.
- Recent onset urinary retention.
- Recent onset faecal incontinence.
- Perianal or perineal sensory loss.
- Unexpected laxity of anal sphincter.
62
Describe the investigations for cauda equina syndrome. (LO4)
- MRI of the spine as soon as possible.
| - Many abnormalities can cause cauda equina syndrome.
63
Describe the non-surgical management of cauda equina syndrome. (LO4)
- Assess using ABCDE approach.
- Once stable, give analgesia.
- In the case of urinary retention, insert catheter.
- Frequent sacral observations.
- Discuss patient with neurosurgery department, emergency transfer to specialist spinal centre.
64
Describe the surgical management of cauda equina syndrome. (LO4)
Urgent surgical decompression should be offered:
- Laminectomy (removal of vertebral lamina) or,
- Discectomy (removal of intervertebral disc).
65
What is a laminectomy? (LO4)
Removal of the vertebral lamina. This is a type of surgical decompression of the spine.
66
What is a discectomy? (LO4)
Removal of the intervertebral disc. This is a type of surgical decompression of the spine.
67
What are the indications for surgical management of cauda equina syndrome? (LO4)
- Lumbar disc herniation: laminectomy +/- discectomy.
- Spinal stenosis: laminectomy.
- Spinal trauma: depends on the mechanism and nature of the injury.
- Malignancy: surgical excision +/- decompression (laminectomy or discectomy).
- Spinal abscess/empyema: laminectomy, evacuation of the abscess +/- discectomy and antibiotics as per local protocol.
68
Describe the prognosis of cauda equina syndrome. (LO4)
CES is a surgical emergency and requires urgent treatment. Even so, the risks are:
- Paraplegia.
- Lower limb numbness.
- Chronic urinary retention or incontinence.
- Chronic sexual dysfunction.
69
List the types of referred pain. (LO5)
- Radicular referred pain.
- Myofascial referred pain.
- Bone/joint referred pain.
- Visceral referred pain.
70
Briefly describe the pathophysiology of pain. (LO5)
Pain is transmitted through the ascending fibres of the spinothalamic tract which gets sensory input from peripheral nociceptors.
71
How does the physiology of pain differ in radicular referred pain? (LO5)
- There is no nociceptor activation.
- Instead, pain is caused by compression of the dorsal root ganglion which holds fibres from most nociceptive neurones.
- Compression of these neurones causes pain in the respective dermatome that that spinal nerve supplies.
72
Define referred pain. (LO5)
Pain experienced in a region not supplied by the location of the stimulus, i.e. pain in a distant site.
73
What is dorsal horn convergence? (LO5)
- Multiple nociceptive inputs from multiple neurones converge into a single second order neurone which produces the perception of pain.
- However, the brain isn't able to distinguish which peripheral neurone the pain signal came from.
- Both radicular and visceral referred pain work by dorsal horn convergence.
74
What is radicular referred pain and how does it occur? (LO5)
Defined as any pain arising from irritation of the nerve root in the spine. This is a type of neuropathic pain.
- Due to the proximal activation of the neurones in the dorsal root ganglion rather than direct activation of the nociceptive terminals.
- This may have an effect on all of the fibres, leading to different effects.
75
Which fibres are affected in radicular referred pain and what is the resulting effect of each? (LO5)
- Aα fibres – muscle function deficit/muscle weakness.
- Aβ fibres – sensory loss.
- Aγ fibres – reflex loss.
- Aδ fibres – pain.
- C fibres – pain.
76
Dorsal root ganglion is not the only thing that can give radicular pain. What else can result in radicular pain? (LO5)
- Distal nerve compression.
- Distal irritation of any individual nerve root branch, downstream from the dorsal root ganglion may give referred pain.
77
How does somatic referred pain occur? (LO5)
- Caused by activation of spinal segmental nerves distal to the dorsal root ganglion.
- This means the nerve root may refer pain to the dermatomal segment.
78
What was Kellgren's procedure and how was it used to investigate referred pain? (LO5)
- The procedure was injecting hypertonic saline into the interspinous ligament between L4 and L5 to produce short-lived intense pain.
- Instead of feeling pain at the injection site (in the spine), the patients felt pain down their legs and in different parts of their legs, depending on which vertebrae were injected.
- E.g. injecting at L4 causes pain of the posterior thigh and superior posterior calf of the right leg.
79
What is myofascial referred pain and how does it occur? (LO5)
- Pain referred from muscles.
- The sensory innervation of a muscle is the same as its motor innervation.
- The pain will also be referred to the muscles sharing the same innervation as the injured muscle.
- Cutaneous representation: area of skin innervated by the specific nerve root will be in pain.
- E.g. the supraspinatus muscle may lie in the T2 dermatome territory but the segmental motor innervation of the muscle arises from C5 and C6.
80
Where does clinical pain at the trapezius muscle radiate to? (LO5)
- Behind the eye.
- Over the temple.
- Proximal neck.
- Sometimes, jaw.
This is because the trapezius is innervated by the 11th cranial nerve.
81
Where does clinical pain at the supraspinatus radiate to? (LO5)
Arm and wrist.
82
What is Hilton's law? (LO5)
A nerve supplying a muscle controlling a joint also innervates the joint.
83
What is bone/joint referred pain and how does it occur? (LO5)
- Bone and joint pain follows a similar pattern to the others, it follows the sclerotomes (segmental distribution of bone and joint pain).
- Sclerotomes are the segmental pattern that is followed by bone and joint pain.
- E.g. patient with osteoarthritis of the hip may have pain referred to the knee.
84
What is visceral referred pain and how does it occur? (LO5)
- Visceral pain is when tissue damage within an organ refers pain to give a cutaneous representation of that pain.
- E.g. tissue damage in the gall bladder refers pain to the right shoulder.
85
Describe the first steps for a patient presenting with spinal pain (first steps). (LO6)
According to NICE guidelines:
1. Examine the patient to document where they're at. This allows us to see if a patient is getting better or not progressing.
2. Do not refer for investigations unless high risk of poor outcome (red flags).
3. Imaging in specialist settings of care only if the result is likely to change management.
4. Educate to self-manage their low back pain and encourage continuation of normal management.
86
Describe the management of mechanical back pain with no red flags. (LO6)
- Analgesia.
- Wait a week: 50% of patients better within a week.
- Wait 6 weeks: 90% of patients better within 6 weeks.
87
List the red flags with back pain. (LO6)
Presence of any of these would require further investigations.
1. Previous history of malignancy.
2. Corticosteroids.
3. Systemically unwell.
4. Weight loss.
5. Widespread neurology.
6. Age <20 years.
7. Age >55 years.
8. Violent trauma.
9. Constant, progressive, non-mechanical back pain.
10. Thoracic pain.
11. IV drug abuse/HIV infection.
12. Persisting severe restriction of lumbar flexion.
13. Structural deformity.
88
List some conservative therapies for spinal pain. (LO6)
- Manual therapy - spinal manipulation, mobilisation or soft-tissue techniques such as massage.
- Psychological therapy - CBT with exercise, with or without manual therapy.
- Promote and facilitate return to work or normal activities of daily living.
- Weak opioids with or without paracetamol.
- Oral NSAIDs.
89
List some non-conservative therapies for spinal pain. (LO6)
- Radiofrequency denervation - focused electrical energy heats and denatures (essentially fries) the nerve with relief lasting for up to 12 months.
- Epidurals/nerve root injections - steroid and anaesthetic injected.
- Spinal fusion - overall no clear advantage of fusion but does show some modest benefit for some elements of pain, function and quality of life.
90
What is radiofrequency denervation? (LO6)
This is done if pain persists.
- A radiofrequency lesion generator produces focused electrical energy which heats and denatures the nerve.
- Relief lasts from 6-12 months.
- This treatment is usually given when other treatments such as facet joint injections have been ineffective for a short period of time and is usually performed to manage back pain and neck pain.
- Can effectively manage pain.
91
Describe how radiofrequency denervation is carried out. (LO6)
- Procedure carried out under x-ray screening.
- A special hollow needle is inserted into the site of injection and a very thin wire is then threaded down inside the needle and attached to the machine at the other end.
- Patient is asked to say when they can feel a tingling or twitching sensation as the doctor tests the machine on different settings.
- This is very important as it makes sure the tip of the needle is in exactly the right place.
- The machine settings are then set to destroy the nerve by heating it for a minute. The patient should not feel anything.
- This process may be repeated at different pain sites, if necessary.
92
What is an epidural? (LO6)
- "Epidural" refers to the space surrounding the outer protective covering of the spinal cord.
- An injection consisting of a steroid, local anaesthetic or a combination of the two.
- Can help to relieve back pain or sciatic pain (shooting pain from the back down one or both legs) in the short term.
- This period of pain relief can allow them to be more active which is crucial to recovery from chronic back pain.
- If the first injection successfully relieves symptoms, up to three injections to the same area of the back may be given over a 6 month period.
93
How is an epidural carried out? (LO6)
- An injection consisting of a steroid, local anaesthetic or a combination of the two.
- Injected into the epidural space using a special needle.
- The position of the injection depends on the spinal nerve responsible for the pain.
- This is usually in the lumbar region of the back (below the level of your lowest rib).
94
What is a nerve root block? (LO6)
- Injection given close to a nerve as it leaves the spine under active CT.
- This type of injection is used if you have back pain radiating to the legs and when it's suspected that this is due to pressure very close to one particular nerve root.
- A nerve root block is not a cure for the cause of the pain.
- But it can be used to help reduce the level of pain.
- Injection is a mixture of local anaesthetic and steroid.
95
What are some benefits of a nerve root block? Focus on the components of the injection. (LO6)
- Local anaesthetics: numb the nerves for a period of hours, giving short-term relief.
- Local steroid: has a long-term effect, reducing inflammation around the nerve root.
96
List the surgical interventions for back pain. (LO6)
- Spinal fusion - 2 or more vertebrae are joined together with a bone graft. No clear advantage of fusion but does show some modest benefit for some elements of pain, function and quality of life.
- Lumbar decompression - relieves pressure on spinal cord/nerves while maintaining as much of the strength and flexibility of your spine as possible.
- Laminectomy - section of bone is removed from one of the vertebrae to relieve pressure on the affected nerve.
- Discectomy - section of the damaged disc is removed.
97
What are the indications for surgical intervention in back pain? (LO6)
- Spinal stenosis.
- Cauda equina syndrome.
- Slipped disc.
- Malignancy.
98
List the treatments NOT recommended by NICE for back pain. (LO6)
1. Belts/corsets - reliance on these can lead to more muscle weakness.
2. Foot orthotics/rocker sole shoes.
3. Traction.
4. Acupuncture.
5. Ultrasound (USS).
6. Percutaneous nerve stimulation.
7. Transcutaneous electrical nerve stimulation (TENS).
8. Interferential therapy - two medium frequency currents passed through the tissues simultaneously.
9. Paracetamol ALONE.
10. STRONG opioids.
11. Antidepressants.
12. Anticonvulsants.
99
Define iatrogenic. (LO7)
Relating to illness caused by medical examination or treatment, e.g. as a result of prescription or medical professional.
100
Define addiction. (LO7)
- A brain disorder (disease) characterised by compulsive engagement in rewarding stimuli, despite adverse consequences.
- A variety of complex neurobiological and psychosocial factors are implicated in the development of addiction.
- More psychological.
101
Is addiction a physical or psychological issue? (LO7)
- More psychological.
102
Define tolerance. (LO7)
- When a person no longer responds to a drug in the way they did at first.
- As a result, it takes a higher dose of the drug to achieve the same effect as when the person first used it.
- This is why people with substance abuse issues use more and more of the drug to get the same "high" they seek.
103
How does tolerance come about? (LO7)
- When a person no longer responds to a drug in the way they did at first.
- As a result, it takes a higher dose of the drug to achieve the same effect as when the person first used it.
- This is why people with substance abuse issues use more and more of the drug to get the same "high" they seek.
104
Define withdrawal. (LO7)
A group of physical and mental symptoms resulting from the cessation of a particular drug (habit).
105
Define dependence. (LO7)
- When a person stops using a drug, their body goes through "withdrawal".
- Many people who take a prescription medicine everyday over a long period of time can become dependent so when they come off the drug, they need to do it gradually to avoid withdrawal discomfort.
- People who are dependent on a drug or medicine aren't necessarily addicted.
- More physical (but can also be psychological).
106
Is dependence a physical or psychological issue? (LO7)
More physical but can also be psychological.
107
Describe the development of addiction. (LO7)
Euphoric and pain-relieving nature of analgesia = high risk of addiction.
1. Opioids trigger the release of endorphins.
2. Endorphins dull perception of pain and boosts feelings of pleasure.
3. This sensation is strongest upon the first dose of analgesia.
4. Once the dose wears off, the patient craves the initial euphoria.
5. To recreate this effect and receive further pain relief, patients may repeatedly take analgesia.
6. As uptake of drugs increases, so does tolerance.
7. So to create the desired effect, dosage must be increased.
108
What is operant conditioning? (LO7)
- A method of learning that occurs through rewards and punishment for behaviour.
- So in this case, drugs usually produce a rewarding experience.
109
Describe the reward pathway leading to addiction. (LO7)
- Drugs activate the reward pathways (mesolimbic dopaminergic pathway).
- Ventral tegmental area (VTA) of the midbrain - medial forebrain bundle - nucleus accumbens + limbic region.
- Even if the drugs' primary sites of action are elsewhere in the brain, they all increase the extracellular level of dopamine in the nucleus accumbens.
- The dopamine release in the nucleus accumbens is also enhanced by naturally rewarding stimuli, e.g. food, water, sex, nurturing.
- Drugs are activating/overactivating the body's own pleasure system.
- In experienced drug users, the anticipation of the effect may be sufficient to lead to a release of dopamine.
110
List the common drugs leading to iatrogenic addiction. (LO7)
Major dependence-inducing drugs:
- Nicotine.
- Ethanol.
- Opioids.
- Cocaine.
- Amphetamine.
- Benzodiazepines.
Cannabis, MDMA and psychedelic drugs are less dependence-inducing.
111
Describe how the patient can prevent iatrogenic opioid addiction. (LO7)
- Use only for <3 days to manage acute pain.
- Take the lowest dose possible, for the shortest time possible.
- Do not use for chronic pain.
- Dispose of unused opioids safely and take how they are prescribed.
112
Describe how the healthcare system can prevent iatrogenic opioid addiction. (LO7)
- Identification of negligent prescribing practices.
- Pursuit of abuse-deterrent drug formulations.
- Measures to prevent misuse and diversion, such as prescription drug monitoring programmes and monitoring of chronic pain treatment through urine testing, medication contracts and mandated electronic prescribing.
- Expanding utilisation of medication-assisted therapies.
- Overdose prevention education and naloxone distribution to prevent overdose fatalities.
113
List the pharmacological therapies that work against opioid addiction. (LO7)
- Buprenorphine and naloxone.
- Methadone.
- Naloxone.
- Naltrexone.
114
How do buprenorphine and naloxone act against opioid addiction? (LO7)
- Eases withdrawal symptoms.
| - Blocks opiate induced euphoria.
115
How does methadone act against opioid addiction? (LO7)
- Eases withdrawal symptoms.
- Binds to opioid receptors.
- Can be used to treat chronic pain.
- Should only be taken at a substance abuse clinic (large doses can produce similar effects to heroin).
116
How does naloxone act against opioid addiction? (LO7)
- Reverses the life-threatening effects of an opioid overdose.
- Prevents opioid highs.
- May cause heightened pain sensitivity.
117
How does naltrexone act against opioid addiction? (LO7)
- Prevents opiate high.
| - Can cause liver damage in high doses.
118
Describe the psychological management of opioid addiction. (LO7)
- Engage in open and honest discussion with patients.
- Agree on a management plan.
- Set achievable goals.
119
List the risk factors for opioid addiction. (LO7)
- Genetics, 50% of addiction risk is inheritance.
- Poverty, unemployment.
- Chronic pain.
- Prior alcohol or drug abuse.
- Dose and duration of opioid prescription.
120
Describe the structure of intervertebral discs. (LO8)
All intervertebral discs have the same basic structure:
- Nucleus pulposus - a central gelatinous mass.
- Annulus fibrosus - a fibrous outer ring.
- Vertebral endplate - a cartilaginous layer covering both the inferior and superior surfaces of the disc.
121
How do the intervertebral discs of the lumbar spine differ from those of the rest of the spine? (LO8)
- The cross-sectional area of the lumbar discs are larger in order to support a bigger weight load.
- Wedge-shaped, contributing to lumbar lordosis.
- Elliptical in shape to resist bending movements (laterally).
122
Describe the function of the nucleus pulposus. (LO8)
The primary function is to redistribute the applied load to the rest of the surrounding disc and its fluid nature allows it to do so.
123
Describe the structure and function of the annulus fibrosus. (LO8)
- The primary load-bearing component of the intervertebral disc is composed of collagen fibres that make up lamellae arranged in rings.
- The annulus fibrosus is thinnest at the posterior aspect of the lumbar spine which is also the area most stressed by torsional forces.
- This leads to this being a common site of injury.
124
Describe the role of the vertebral endplate. (LO8)
The vertebral endplate plays a role in the metabolism of the avascular intervertebral disc in adults and supports the annulus fibrosus.
125
Describe how disc herniation can occur. (LO8)
- The inner disc material encroaches on the spinal cord or nerve roots.
- This generally occurs due to a lesion in the annulus fibrosus and vertebral endplate and also due to the degradation of the nucleus pulposus.
- More likely to occur when the disc is hydrated so not generally associated with old age (as the discs become dehydrated with age).
126
Describe the ways in which pain can arise from the lumbar spine. (LO8)
- Mechanical compression of the nerve root, dorsal root ganglion or smaller nerves surrounding the disc.
- Pain sensitive nerve endings.
- Mechanical stimulation to the posterior annulus fibrosus can produce chronic back pain. Showing nerve root involvement isn't necessary for the presence of pain as inflammation can cause this itself.
127
Where does the spinal cord run between? (LO9)
Extends from the brain (foramen magnum) to around L1 and L2 for adults (L3 for children).
128
Describe the function of the spinal cord and its associated spinal nerves. (LO9)
- Receive afferent fibres from the sensory receptors of the trunk and limbs.
- Control movements of the trunk and limbs.
- Provide autonomic innervation for most of the viscera.
- The internal organisation of the cord permits many functions to operate in an automatic or reflex fashion.
129
List the regions the spine is split into and how many vertebrae does each consist of? (LO9)
- Cervical spine: C1-C8.
- Thoracic spine: T1-T12.
- Lumbar spine: L1-L5.
- Sacral region: S1-S5.
- Cauda equina.
- Coccygeal region: 1 pair of coccygeal nerves.
- Filum terminale: becomes a component of the coccygeal ligament and attaches to the dorsal surgae of the first coccygeal vertebra.
130
How do the spinal nerves of C8 differ from those of C1-C7? (LO9)
- C1-C7: spinal nerves exit from the vertebral canal above the corresponding vertebrae.
- C8: spinal nerves exit from below the C7 and the remainder leave below C8.
131
How does the discrepancy in spinal cord length and vertebral column length affect the spinal nerves? (LO9)
- Because of this discrepancy, it's only in the cervical region that the spinal cord segments lie adjacent to their corresponding vertebral bodies.
- Below C8, successive spinal nerve roots follow an increasingly oblique and long downwards course to reach their respective intervertebral foramina.
- This is most apparent for the lumbar and sacral roots which descend below the termination of the cord in a leash-like arrangement (the cauda equina).
132
What is the cervical enlargement? (LO9)
- This is the segment of the spinal cord running from C4-T1.
| - It is the source of the spinal nerves supplying the upper limb via the brachial plexus.
133
What is the lumbosacral enlargement? (LO9)
- This is the segment of the spinal cord running from L1-S3.
| - It is the source of the spinal nerves supplying the lower limb via the lumbosacral plexus.
134
What is the cauda equina? (LO9)
The lumbosacral nerves originating at the end of the spinal cord which descend further than the spinal cord itself before exiting the vertebral column.
135
What are the three spinal meninges? (LO9)
- Pia mater.
- Arachnoid mater.
- Dura mater.
136
What is the pia mater? Describe the pia mater. (LO9)
- A delicate vascular membrane that is closely applied to the surface of the cord and nerve roots.
- Along a line, midway between the dorsal and ventral roots of the spinal nerves, is attached, the dentriculate ligament.
137
What is the dentriculate ligament? (LO9)
- A flat, membranous continuation of the pia mater.
- Attached to a line, midway between the dorsal and ventral roots of the spinal nerves.
- The ligament has a free lateral border for much of its length.
- Intermittently, lateral projections tether the spinal cord to the arachnoid, and through it to the dura.
138
What is the arachnoid mater? Describe the arachnoid mater. (LO9)
- Translucent membrane that envelopes the cord like a loose-fitting bag.
- Arachnoid mater lies between the pia and dura maters.
- Between the pia mater and arachnoid mater, lies the subarachnoid space.
- The subarachnoid space contains CSF which is produced in the cerebral ventricular system.
139
Where is the subarachnoid space located? (LO9)
Between the pia mater and arachnoid mater.
140
What fluid is contained within the subarachnoid space? (LO9)
Cerebrospinal fluid (CSF) produced in the cerebral ventricular system.
141
What is the dura mater? Describe the dura mater. (LO9)
- The outer covering of the cord.
- A tough fibrous membrane.
- It envelops the cord loosely, as does the arachnoid.
- It is in contact with the arachnoid but they are separated by a theoretical plane.
- It is separated from the bony wall of the vertebral canal by the epidural space.
- The theoretical plane is called the subdural space.
142
Describe the relationship between the spinal meninges and the spinal cord. (LO9)
- The spinal cord terminates at vertebral level L1-L2.
| - The arachnoid and dura sheaths, and therefore the subarachnoid space continue caudally to S2.
143
Explain the pathway of the spinal nerve roots through the meninges and out of the spine. (LO9)
- The spinal nerve roots pass towards their intervertebral foramina and evaginate the arachnoid and dura, forming meningeal root sleeves.
- The meningeal root sleeves extend as far as the fusion of dorsal and ventral roots.
- The arachnoid and dura then become continuous with the epinerium ensheathing the spinal nerve.
144
The spinal cord is divided into two symmetrical halves by which two structures? (LO9)
- The dorsal median sulcus.
| - The ventral median fissure.
145
Describe the structure of the spinal cord. (LO9)
- The small central canal (centre of the cord) - continuous rostrally with the cerebral ventricular system.
- Spinal grey matter surrounding the central canal - consists of nerve cell bodies, their dendrites and synaptic contacts.
- White matter (outer part) - contains ascending and descending nerve fibres. Some of these serve to join neighbouring and distant cord segments for the integration of their functions, while others run between the cord and the brain.
- Many of the fibres that share a common origin, course and termination are grouped together in fascicles, forming the long tracts of the spinal cord.
146
Describe the pathway of the main afferent fibres entering through the dorsal roots. (LO9)
Afferent fibres entering through the dorsal roots divide into the ascending and descending branches. They mostly terminate near their point of entry but may travel for varying distances in either direction, running in dorsolateral fasciculus/Lissauer's tract.
- Dorsal root afferents may establish synaptic contacts over several segments of spinal grey matter.
- Dorsal root fibres terminate extensively within grey matter but most densely in dorsal horn.
- Cutaneous afferents tend to terminate in superficial (dorsal) laminae.
- Proprioceptive and muscle afferents project mostly to deeper laminae.
147
Describe the structure of the central canal of the spinal cord. (LO9)
- Dorsal and ventral roots merge to form a spinal nerve.
- Dorsal root: sensory nerves.
- Ventral root: motor nerves.
- Lateral horn (only in T1-T2): preganglionic motor neurones of sympathetic nervous system.
148
Which nerves is the dorsal root typically made up of? (LO9)
Sensory nerves.
149
Which nerves is the ventral root typically made up of? (LO9)
Motor nerves.
150
Which nerves is the lateral horn typically made up of? (LO9)
Preganglionic motor neurones of the sympathetic nervous system (only in T1-T2).
151
How many spinal nerves are contained within the spinal cord? (LO9)
- The spinal cord bears 31 bilaterally paired spinal nerves.
| - Each pair is associated with its corresponding cord segment.
152
Describe the origination and pathway of a typical spinal nerve. (LO9)
- Spinal nerves originate as 2 linear series of nerve fascicles/rootlets, attached to dorsolateral and ventrolateral aspects of cord.
- Dorsal and ventral roots of each cord segment then pass to their corresponding intervertebral foramen, in or near which they join to form the spinal nerve proper.
- Immediately after leaving the intervertebral foramina, spinal nerves divide to produce a thin dorsal (posterior) ramus and a much larger ventral (anterior) ramus.
- The dorsal ramus supplies the muscles and skin of the back region.
- The ventral ramus supplies the muscles and skin of the front of the body and also the limbs.
153
Which is larger, the dorsal or ventral rami? Which parts of the body do each of these supply? (LO9)
- The ventral ramus is MUCH larger than the dorsal ramus.
- The ventral ramus supplies the muscles and skin of the front of the body and also the limbs.
- The dorsal ramus supplies the muscles and skin of the back region.
154
What is meant by dorsal root ganglia? (LO9)
- Small enlargements on dorsal roots near their convergence with the ventral roots at the entrance to the intervertebral foramina.
- Nerve cell bodies of the neurones of the dorsal roots are in the dorsal root ganglia.
155
Describe the structure of a typical spinal nerve. (LO9)
Spinal nerves are mixed nerves, containing both afferent and efferent neurones.
156
Describe the structure of dorsal roots in the spinal nerve. (LO9)
- Dorsal roots contain primary afferent neurones, running from peripheral sensory receptors to the spinal cord and brainstem.
- Nerve cell bodies of these neurones are in the dorsal root ganglia: small enlargements on dorsal roots near their convergence with the ventral roots at the entrance to the intervertebral foramina.
157
Describe the structure of ventral roots in the spinal nerve. (LO9)
- Ventral roots contain efferent neurones: motor neurones innervating skeletal muscle and preganglionic neurones of the autonomic nervous system.
- Nerve cell bodies are located in the spinal grey matter.
