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MSK > Spine (Degeneration, Lower back pain and disc prolapse) > Flashcards

Spine (Degeneration, Lower back pain and disc prolapse) Flashcards

1
Q

What type of joints are faecet joints of the lumbar spine and what movements do they allow?

A

True synovial joints

Mainly flexion and extension

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2
Q

What types of joints are intervertebral discs of lumbar spine and what movements do they allow?

A

Secondary cartilaginous joints

Movement between vertebrae

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3
Q

Where is the anterior longitudinal ligament (ALL)?

A

Along the front of the vertebral bodies

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4
Q

Where is the posterior longuitdinal ligament (PLL)?

A

Along the backs of the vertebral bodies i.e. front of the spinal canal

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5
Q

Where is the ligamentum flavum?

A

Between laminae

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6
Q

Where is the interspinous and supraspinous ligament found?

A

Between spinous processes

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7
Q

Where is the intertransverse ligament found?

A

Between transverse processes

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8
Q

Where is the pain worse in nerve root pain?

A

Limb pain is worse than back pain

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9
Q

Presentation of nerve root pain

A

Pain (back, limbs)
Root tension signs
Root compression signs

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10
Q

Treatment of nerve root pain

A

most settle about 90% in 3 months
physio
strong analgesia
MRI

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11
Q

Normal ageing process of the spine

A

decreased water content of discs
disc space narrowing
“degenerative changes” on X rays
degeneration changes in faecet joints

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12
Q

What is the ageing process of the spine aggrevated by?

A

Smoking

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13
Q

Where are degenerative changes seen in cervical and lumbar spondylosis (OA)?

A

faecet joints
discs
ligaments

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14
Q

What can severe cervical/lumbar spondylosis cause?

A

Can compress the whole cord (not just the nerve roots) causing myelopathy
- UMN signs in limbs (increased tone, brisk reflexes etc)

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15
Q

What is lumbar spondylosis?

A

OA of faecet and disc joints (+degeneration of ligaments etc)

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16
Q

Who is spinal claudication/stenosis very common in?

A

patients > 60 y/o

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17
Q

Types of spinal claudication/stenosis

A

Lateral recess stenosis
Central stenosis
Foraminal stenosis

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18
Q

Treatment of lateral recess stenosis

A

non operative
nerve root injection
epidural injection
surgery

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19
Q

Treatment of central stenosis

A

non operative
epidural steroid injection
surgery

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20
Q

Treatment for foraminal stenosis

A

non-operative
nerve root injection
epidural injecton
surgery

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21
Q

Most common cause of spinal cord injuries

A

RTAs
sports and recreational activities
falls

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22
Q

Criteria/presentation of a complete injury (grade A) to spinal cord

A

No motor or sensory function
no anal squeeze
no sacral sensation
no chance of recovery

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23
Q

What is the grading system for spinal cord injuries?

A

ASIA grading

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24
Q

Presentation of incomplete injury of spinal cord

A

Some function still present below the site of the injury

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25
Q

ASIA grade A

A

Complete

no sensory or motor function preserved in sacral segments S4-5

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26
Q

ASIA grade B

A

Incomplete

Sensory but not motor function preserved below neurological level and extending through sacral segments S4-5

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27
Q

ASIA grade C

A

Incomplete

motor function preserved below the neurological level; majority of key muscles have grade < 3

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28
Q

ASIA grade D

A

Incomplete

Motor function preserved below the neurological level; majority of key muscles have a grade > 3

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29
Q

ASIA grade E

A

normal motor and sensory function

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30
Q

Definition of tetraplegia/quadraplegia

A

Partial or total loss of use of all 4 limbs and the trunk

31
Q

Definition of paraplegia

A

Partial or total loss of the use of the lower limbs

32
Q

What can cause tertraplegia/quadriplegia?

A

Cervical fractures

33
Q

What can cause paraplegia?

A

Thoracic/lumbar fractures

34
Q

Examples of partial cord syndromes

A

central cord syndrome
anterior cord syndrome
brown-sequard syndrome

35
Q

Features of central cord syndrome

A 
older patients (arthritic neck)
hyperextension injury 
central cervical tracts more involved 
weakness of arms > legs
perianal sensation and lower extremity power conserved
36
Q

Features of anterior cord syndrome

A 
Hyperflexion injury 
anterior compression fracture
damaged anterior spinal artery 
fine touch and proprioception preserved
profound weakness
37
Q

Features of brown - sequard syndrome

A

Hemisection of the cord
Penetrating injuries
Paralysis of affected side (corticospinal)
Loss of proprioception and fine touch discrimination (dorsal columns)
Pain and temp loss on opposite side below lesion (spinothalamic)

38
Q

Treatment of spinal cord injuries

A

KEY IS TO PREVENT SECONDARY INSULT
ABCD
- airway = C spine control
- breathing = ventilation + O2, concomitant chest injuries
- circulation = IV fluids, consider neurogenic shock
- disability = Assess neurological function
ATLS = advanced trauma life support
X rays
CT
MRI - if neurological deficit or children
Surgical fixation for unstable fractures

39
Q

Long term management of spinal cord injury

A

spinal cord injury unit
OT
psychological support
urological/sexual counselling

40
Q

Definition of spinal shock

A

A type of shock that causes a temporary reduction of or loss of reflexes following a spinal cord injury. Transient depression of the cord function below the level of the injury

41
Q

Presentation of spinal shock

A

flaccid paralysis

areflexia (muscles overreact to stimuli)

42
Q

Symptoms of neurogenic shock

A

hypotension
bradycardia
hypothermia

43
Q

What is neurogenic shock secondary to?

A

Disruption of sympathetic outflow

44
Q

Definition of neurogenic shock

A

A type of shock resulting in low BP and slowed HR which is attributed to the disruption of autonomic pathways within the spinal cord

45
Q

Two types of lumbar disc prolapse

A

lateral disc protrusion

central disc protrusion

46
Q

What position are disc prolapses usually?

A

Postero-lateral

47
Q

What In the lumbar disc prolapse can cause cord/nerve root compression?

A

Annulus may tear + nucleus prolapse

48
Q

Types of disc problems

A

Buldge (generalised) - mainly asymptomatic
Protrusion = annulus weakned but still intact
Extrusion = thought anulus but incontinuity
sequestrian = dessicated sic material free in canal

49
Q

Where are cervical dis prolapses most common?

A

C5/6

50
Q

Least common area of the spine for disc prolapses

A

Thoracic spine as doesn’t move as much

51
Q

Most common thoracic area for disc prolapse

A

T11/12

52
Q

Where are lumbar disc prolapses most common?

A

L4/5, then L5/S1, then L3/4

53
Q

What is cauda equina syndrome a result of?

A

compression of the cauda equina

54
Q

Management of cauda equina syndrome

A

URGENT MRI scan

emergency operation within 48 hours of onset - dissectomy

55
Q

Causes of cauda equina syndrome

A 
Central lumbar disc prolapse - COMMONEST
tumours
trauma 
- burst or chance fracture disc 
- spinal stenosis 
infection - epidural abscess
iatrogenic 
- spinal surgery/manipulation 
- spinal epidural infection
56
Q

Presentation of cauda equina syndrome

A 
Sudden - injury or precipitating event 
Bilateral buttock and leg pain 
Varying dyskinesia and weakness 
Urinary retention +/- incontinence overflow 
bowel dysfunction 
saddle anaesthesia (perianal loss of sensation) 
loss of anal tone
loss of anal reflex
57
Q

investigation of cauda equina syndrome

A

MRI

if contraindicated = lumbar CT myelogram

58
Q

What pathology does a positive straight leg raise test indicate?

A

Sciatic nerve pain

59
Q

Red flags for back pain

A 
Thoracic back pain 
Age < 20 or > 55 
Non mechanical pain 
Pain worse when supine
Night pain 
Weight loss
Pain associated with systemic illness 
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steriod use 
IV drug use
Structural deformity
60
Q

What does a prolapsed lumbar disc usually present with?

A

Clear dermatomal leg pain associated with neurological deficits

61
Q

Features of a prolapsed disc

A

Leg pain usually worse than back

Pain often worse when sitting

62
Q

Features of an L3 root compression

A

Sensory loss over anterior thigh
Weak quads
Reduced knee reflex
Positive femoral stretch test

63
Q

Features of L4 root compression

A

Sensor loss over anterior aspect of knee
Weak quads
Reduced knee reflex
Positive femoral stretch test

64
Q

Features of L5 root compression

A

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

65
Q

Features of S1 root compression

A

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexor of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

66
Q

Management of lumbar disc prolapse

A

Analgesia
Physio / exercises
If symptoms persistent i.e. beyond 4 - 9 weeks then consideration of MRI

67
Q

What is discitis?

A

An infection of the intervertebral space

68
Q

Presentation of discitis

A

Back pain
Fever / rigors / sepsis
Neurological features e.g. change in lower limb signs (if epidural abscess develops)

69
Q

Causes of discitis

A

Bacterial (Staph A most common)
Viral
TB
Aseptic

70
Q

Investigations of discitis

A

MRI

CT guided biopsy may be needed to guide Ax Tx

71
Q

Treatment of discitis

A

IV Antibiotics 6 - 8 weeks

72
Q

Complications of discitis

A

Sepsis

Epidural abscess

73
Q

What % of sciatica resolves spontaneously with conservative treatment within 3 months?

A

90%

74
Q

When would sciatica be routinely referred to spinal surgery?

A

Failure of conservative treatment after 4 - 6 weeks

MSK (25 decks)

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