Spinal Disorders

Question 1

Lower back pain can be a sign of what?

Answer 1

Malignancy 
Infection 
Fracture
Cauda Equina Syndrome
Inflammatory disease for spine

Question 2

What are the red flags for malignancy in the spine?

Answer 2

History of cancer
Unexplained weight loss
Failure to improve symptoms of pain
Peripheral neurology compromise

Question 3

What are the red flags for fracture in the spine?

Answer 3

History of trauma
Corticosteroid use - weakens the bone
Age over 65 and female
Pain referred to the lower limbs - fractures can compress the nerve.

Question 4

What are the red flags for infection in the spine?

Answer 4

Fever / Rigors
Recent serious illness / infection
Non-mechanical pain
Diabetes
Age over 65
History of spinal surgery / injection

Question 5

What are the red flags for cauda equina syndrome in the spine?

Answer 5

Urinary retention - big indicator
Perianal sensation loss
Reduced anal tone
Bilateral leg pain
Erectile dysfunction

Question 6

Urinary retention

Answer 6

Urinary retention is a condition in which your bladder doesn’t empty completely even if it’s full and you often feel like you really have to urinate.

Question 7

Cauda equina syndrome effects where in the spine?

Answer 7

The nerve roots L1-S2

Question 8

What common inflammatory spinal conditions exist?

Answer 8

Ankylosing spondylitis

Question 9

Ankylosing spondylitis

Answer 9

Ankylosing spondylitis (AS) is a autoimmune arthritis that causes pain and stiffness in your spine. This lifelong condition, also known as Bechterew disease, usually starts in your lower back. It can spread up to your neck or damage joints in other parts of your body.

Question 10

What are the red flags for an underlying inflammatory condition in the spine? (Ankylosing spondylitis).

Answer 10

Pain and prolonged morning stiffness
Commonly young males
Uveitis
Gluteal pain

Question 11

Uveitis

Answer 11

Uveitis is a form of eye inflammation. It affects the middle layer of tissue in the eye wall. They include eye redness, pain and blurred vision.

Question 12

Lumbar disc herniation symptoms

Answer 12

Symptoms of a slipped disc include lower back pain, neck pain and difficulty bending your back.

Question 13

How does acute cauda equina compression present?

Answer 13

Bilateral pain in both legs. Saddle anaesthesia (perianal). Urinary retention and loss of anal tone leading to bowel incontinence.

Question 14

Spondylosis

Answer 14

Degenerative disc disease - is part of the normal ageing process and can lead to mechanical back pain. Spondylosis can lead to disc herniation and spinal stenosis.

Question 15

What are the degrees of disc herniation?

Answer 15

Disc protrusion
Nuclear extrusion
Sequestered nucleus

Question 16

Disc protrusion

Answer 16

Disc protrusion - the ruptured nucleus distorts the outermost fibers of the annulus causing them to bulge outward. The term “prolapsed disc” is synonymous with protrusion or bulging.

Question 17

Nuclear extrusion

Answer 17

Nuclear extrusion - a complete split in the annulus that allows nuclear material to leak out into the surrounding
spaces. The protruded material remains attached to the nuclear material remaining inside the disc.

Question 18

Sequestered nucleus

Answer 18

Sequestered nucleus - the extruded nuclear substance is no longer attached to the material remaining inside of the disc. The sequestered fragment(s) may float around the spinal canal and become totally remote from the site from which it originally extruded.

Question 19

Why can disc herniation cause sciatica?

Answer 19

Most disc herniations in the canal occur lateral to the margins of the PLL. This puts the disc herniation in a position to physically contact and exert pressure on the exiting nerve root at
that level.

The individual may begin experiencing
pain down the back of the leg or sciatica.

Question 20

Explain sciatic pain.

Answer 20

Sciatica can be caused by tension (stretching) mechanism of the nerve root over the bulging disc.
A mechanical compression of the nerve root between the bulging disc material and the posterior canal structures i.e stenosis.

Question 21

Explain crualgia vs sciatica

Answer 21

Cruralgia = pain referred to above the knee: L1, L2, L3 nerve root compression

– Sciatica = pain referred to below the knee: L4, L5, S1 nerve root compression

Question 22

Crualgia indicates which nerve roots are affected?

Answer 22

L1 L2 L3

Question 23

Sciatica indicates which nerve roots are affected?

Answer 23

L4 L5 S1

Question 24

What are the symptoms of nerve root compression?

Answer 24

– Motor weakness in IP (L1,L2), QF (L2, L3)
– Motor weakness in TA (L4)
– Motor weakness in EHP/EDC (L5) foot drop
– Motor weakness in plantar flexion (S1)

Question 25

L4 palsy affects where?

Answer 25

Tibia and dorsiflexion of the foot - appears as a foot drop when walking.

Question 26

What are the signs of spinal infection?

Answer 26

Tender spine
Raised temperature
High WCC
High ESR and CRP

Question 27

What is the difference between cauda equina syndrome and conus medullaris?

Answer 27

Cauda equina typically causes severe pain, while conus medullaris results in mild to moderate pain, if any pain at all is present. Conus medullaris can be caused by an injury, lesion, or infection, while cauda equina is almost always caused by a lesion or infection.

Question 28

Cauda equina syndrome

Answer 28

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control.

Question 29

What are the symptoms of cauda equina syndome?

Answer 29

Back pain, radicular pain down the legs, asymmetric, atrophic, areflexic, paralysis of the legs. Sensory loss in root distribution. Loss of sphincter tone.

Question 30

Cauda equina results from compression where?

Answer 30

Compression of the roots distal to L1.

Question 31

What can cause cauda equina?

Answer 31

Disc prolapse (1-2% of all lumbar disc herniations)
Trauma (fracture, dislocation)
Stenosis (usually with acute disc herniation)
Epidural Infection (iatrogenic or haematogenous)
Tumours (compression, epidural spread)

Question 32

Why do patients with cauda equina initially present with pain?

Answer 32

Larger fibres (motor/joint position/light touch) less susceptible than smaller fibres (pain/parasympathetic).

Question 33

A nerve can be compressed for up to 6-8hours after which it will become ischaemic.

Answer 33

A nerve can be compressed for up to 6-8hours after which it will become ischaemic.

Question 34

Why are males less susceptible to permanent bladder damage from overdistension?

Answer 34

Males do not have a bladder and so can hold a larger volume of urine in their bladder. Therefore more attention is needed towards females presenting with bladder retention symptoms.

Question 35

Spinothalamic tract detects…

Answer 35

Soft touch, temperature and pain.

Question 36

Summarise bladder dysfunction in cauda equina syndrome.

Answer 36

Infrasacral - Below S2 - Conus/cauda equina/peripheral nerves. Results in:
Detrusor areflexia
Overflow incontinence

Note: Suprasacral above S2 due to spinal cord injury and tumours results in: Detrusor hyperreflexia.

Question 37

What are the three types of cauda equina syndrome?

Answer 37

Early CESE
– Bilateral leg pain and altered sensation
– Perianal region decreased sensation
– Lower limb bilateral motor power abnormality

Incomplete CESI
– As above + reduced sphincter function
(bowel and bladder)

CESR (Retention) -
– Inability to pass urine or control bowel.

Question 38

How is cauda equina syndrome managed?

Answer 38

CESE - monitor, MRI
CESI - urgent operative decompression < 24h
CESR - operative decompression

Question 39

Why does cauda equina usually present with bilateral pain but unilateral motor deficit?

Answer 39

The nerve root pain fibres are smaller and more susceptible to compression where as the motor fibres are larger and so respond less to the compression over time.

Question 40

What are the outcomes for people with cauda equina?

Answer 40

CESI - 75% return to acceptable normal sexual, bladder, social and bowel function. Chronic pain.
CESR - no return to acceptable normal sexual, bladder, social and bowel function. Chronic disabling pain.