Clinical - Spine

Question 1

Spondylosis

Answer 1

Degeneration of the spinal column from any cause.

Question 2

What is the treatment for spondylosis/OA?

Answer 2

Facet joint injections of steroids and anaesthetic under fluoroscopy or spinal fusion

Question 3

In which vertebrae is intervertebral disc degeneration and acute disk prolapse most common?

Answer 3

L4/5 and L5/S1 (lower to bear more weight)

Question 4

Is MRI diagnostic for intervertebral disc degeneration and acute disk prolapse, and why?

Answer 4

No, because many people have bulging discs on MRI with no symptoms

Question 5

What is the typical history for an acute disc prolapse (annular tear)?

Answer 5

Lifting heavy object then felt a twang. Pain on coughing and settled within 3 months

Question 6

Which nerve root is commonly compressed in disc prolapse, traversing or exiting?

Answer 6

Traversing root, specifically the lower root e.g. L5 for L4/L5 disc prolapse

Question 7

Radiculopathy

Answer 7

Conditions where the nerve root is affected, and the pain/symptoms generally radiate to the areas which that nerve root serves ie. dermatome/myotome

Question 8

Sciatica

Answer 8

Radiculopathy of the nerve roots contributing to the sciatic nerve - causing radiation of nerve pain along sensory distribution of Sciatic nerve

Question 9

Spinal stenosis

Answer 9

Compression of the spinal cord or nerve roots due to narrowing of spinal canal by osteophytes and hypertrophied ligaments (eg. in OA)

Question 10

Neurogenic claudication

Answer 10

Radiculopathy or burning leg pain on walking

Question 11

Cauda Equina Syndrome

Answer 11

Pressure (usually prolapsed disc) on all lumbosacral nerve roots at level of lesion including sacral nerve roots for bladder and bowel control

Question 12

Chance fracture

Answer 12

Flexion injuries causing fractured vertebral body with disruption posterior ligaments with or without fracture of posterior elements

Question 13

What are the important features of a prolapsed disc?

Answer 13

Leg pain (sciatica) often accompanied with neurological disturbance

Question 14

What is the purpose of surgery in prolapsed IV discs and when should it be considered?

Answer 14

To treat the leg pain, primarily. Disc prolapse itself will often settle on its own. Surgery should be considered if there is unresolving pain lasting more than 3 months

Question 15

What is the most important approach to backache without sciatica: best rest and immobility, or keeping as mobile as possible with slight exercise?

Answer 15

Keeping as mobile as possible with exercise as tolerated (bed rest is now discredited)

Question 16

Adjacent Segment Disease

Answer 16

Symptomatic deterioration of spinal levels adjacent to the site of a previous fusion

Question 17

What are the 4 main categories of scoliosis?

Answer 17

Congenital, early onset idiopathic, late onset idiopathic and secondary

Question 18

What is the common theme of congenital scoliosis?

Answer 18

An imbalance in the number of growth plates (e.g. unilateral hemivertebrae)

Question 19

Hester-Volkmann’s Law in Idiopathic Scoliosis

Answer 19

Increased pressure across an epiphyseal plate inhibits growth

Question 20

What is the latest research on the aetiology of idiopathic scoliosis?

Answer 20

Genetic fault in melatonin receptors, leads to hyper excitability of motor cortex

Question 21

What does the spine have an inherent tendency to go into kyphosis?

Answer 21

Centre of gravity is anterior to the spine, and there is high pre-load. Fault in the ‘guy ropes’ of the spine - erector spinae muscles - will result in kyphosis also

Question 22

Spondylolysis

Answer 22

A defect in the pars interarticularis (ossification centres) of the vertebra

Question 23

Spondylolisthesis

Answer 23

The forward slippage on one vertebra on another

Question 24

Which grading system is used for Sponylolisthesis?

Answer 24

Meyerding

Question 25

What are the 2 main surgical emergencies in back pain?

Answer 25

Cauda equina syndrome and nerve root deficit/fracture with deteriorating neurology

Question 26

Which grading system is used for spinal cord involvement?

Answer 26

Frank/ASIA gradig

Question 27

Spinal cord involvement can be divided into complete and incomplete, what are the 2 divisions of incomplete?

Answer 27

Central cord, Brown - Sequard and anterior cord

Question 28

What is the typical situation in a Central, Brown and anterior cord injuries?

Answer 28

Central - hyperextension injury; Brown-Sequard - Trauma associated with fracture; Anterior - vascular insult

Question 29

What might you see on an MRI of a patient with Lower Back Pain? (Clue: LOSS)

Answer 29

Loss of joint space, Osteophytes, Sclerosis, Subarticular cysts

Question 30

What is the typical presentation for spinal claudication?

Answer 30

Age 50+, male, possible manual worker and/or obese, sit/lean forward to relieve symptoms and have ‘heavy/tired’ legs

Question 31

What are the characteristics of discogenic pain?

Answer 31

Worse as day goes on, with flexion or with activity.

Deep seated central low back pain

Question 32

What are the characteristics of the pain with facet arthropathy?

Answer 32

Difficulty sitting, driving, standing; Worse with extension; Better with activity. Often radiates to buttocks and legs

Question 33

Neurogenic claudication

Answer 33

Painful cramping and weakness in the legs associated with a neural problem, e.g. in lumbar stenosis or inflammation in the nerve roots

Question 34

What is the difference between spinal and vascular claudication in terms of when it is relieved?

Answer 34

Spinal is relieved on flexing, while vascular is relieved by standing

Question 35

Discogenic pain

Answer 35

Pain originating from a damaged vertebral disc, particularly due to degenerative disc disease.

Question 36

Segmental instability

Answer 36

A pattern of pain, typically a background ache, with exacerbations and remissions superimposed, often for no apparent reason.

Question 37

Facet Arthropathy

Answer 37

Pain and discomfort that caused by degeneration and arthritis of the facet joints of the spine.