Back Pain

Question 1

Name this abnormal curvature of the spine [1]

Which vertebrae does this most commonly occur in? [1]

Answer 1

Scheuermann kyphosis

Condition of hyperkyphosis that involves the vertebral bodies and discs of the spine identified by anterior wedging of greater than or equal to 5 degrees in 3 or more adjacent vertebral bodies

Thoracic spine is most commonly involved, although involvement can include the thoracolumbar/lumbar region as well

Question 2

State the normal curvatures of the spine [4]l if they are primary or secondary [4] and if they are kyphosis or lordosis [4]

Answer 2

cervical: secondary: lordosis
thoracic: primary; kyphosis
lumbar: secondary; lordosis
sacral: primary; kyphosis

Question 3

Which condition caused this kyphosis [1]

Answer 3

Osteoporosis

Question 4

A hunchback is an exaggeration of what type of normal curve? [1]

How does a hunchback occur? [1]

Answer 4

Increased thoracic kyphosis

Erosion/fracture of anterior part of one or more vertebrae

Question 5

How does osteoporisis cause kyphosis? [1]

Answer 5

loss of trabaculae bone inside the vertebral body; causes anterior wedge that increases the curvature of the thoracic region

Question 6

Describe mechanism of treating XS kyphosis using Kyphoplasty (vertebroplasty, vertebral augmentation) [4]

Answer 6

• Put in a small tube that has balloon in it
• Inflate balloon
• This lifts the vertebral body up
• Pump in bone cement PMMA
• Solidifies the trabeculae and lifts the vertebrae up

Question 8

Describe the pathophsioloy of adolescent kyphosis: Sheuermann’s disease [3]

Answer 8

Epiphyseal growth plates of vertebral bodies are affected in one or more thoracic vertebrae; causes Smorl’s nodes

Smorl’s nodes: nucleus pulposes pushes into the vertebral body above it

Causing wedging of the bone and exaggerated kyphosis

Question 9

What are the arrows pointing to?

Answer 9

Schmorl’s nodes are a common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through an endplate defect.

Question 10

Describe treatment used for adolescent kyphosis (Sheuermann’s disease) [3]
How much doe

Answer 10

Physiotherapy
Increased strength of paraspinals

Bracing
Less than 65o
Corrects by 15o

Surgical
Curves greater than 65o
Intractable pain or neurological issues

Question 11

Which curvature does this show?

Answer 11

Lordosis

Question 12

State three causes of lumbar lordosis [3]

Answer 12

Associated with weakened trunk muscles.
Can develop in late pregnancy or with obesity: more anterior weight
Or weakened hip flexors (ilopsoas)

Question 13

Name a pathological disease that causes lordosis

Answer 13

Muscular dystrophy

Question 14

Symptoms for lordosis? [2]

Answer 14

Back ache
Sciatica: impingement of nerve root

Question 15

Describe the pathophysiology of XS lordosis [3]

Answer 15

Vertebral bodies designed for weight bearing but now weight is shifted onto posterior elements: especially the facet joints; can sublux due to not being aligned

Inverterbral disc narrowed at the back; but stretched at the front - can cause hernation

Small intervertebral foramina can impinge exit of large spinal nerves

Question 16

Which muscles particularly causes lordosis? [2]

Explain why this occurs [3]

Answer 16

Ilopsoas; psoas major and iliacus: hip flexors

Chronic psoas shortening and tightness causes increased lordosis

Also results compensatory stretching and weakness of abdominal muscles AND
Hamstring and gluteal muscles tightened often hypertonic

Question 17

Describe the how flat back syndrome is caused [1]

Describe the effects having a flat back has on the following and what this means physiologically [8]

• Ribs
• Hamstrings
• Hip flexors
• Head

Answer 17

Pelvic tilts backwards and and pulls lumbar spine flat. Causing:

• Tight musculature between ribs makes breathing shallow
• Hamstrings tight – knees flexed
• Hip flexors weak – hip flexed (gravity)
• Pelvis tilts backwards pulls vertebral column flat
• Head forward – puts stress on shoulder and neck

Question 18

Which immunological disease can cause flat back syndrome? [1]

Name two other causes [2]

Answer 18

Ankylosing spondylitis

degenerative disc; spinal fusion

Question 19

Why may girls develop scoliosis more than boys? [1]

Answer 19

Relaxin is released during menstrual cycle

Question 20

How do you assess to see if have scoliosis? [1]

What other sign may scoliosis patients have? [1]

Answer 20

Ask to bend over; look at shoulder difference

One pelvis is higher than the other - apparent leg length discrepency (but not actually)

Question 21

What degree of curvature would indicated scoliosis:

Brace [1]
Surgery [1]:
* what surgical interventions could you use? [2]

Answer 21

Brace: 20-40 degrees
Surgery: > 50 degrees
* Vertebral fusions
* Harrington rods

Question 22

Name this treatment for scoliosis [1]

Answer 22

Harrington rods

Question 23

Describe age related changes that are pathological to the spinal cord [2]

Answer 23

After the age of 30 IV discs dry out – nucleus pulposus dries out due to reducting in proteoglycan structure

Osteoarthritis: osteophytes

Ossification of vertebral ligaments

Spinal Stenosis

Question 24

Posterior osteophytes impinge of which structure? [1]

Anterior osteophytes impinge of which structure? [1]

Answer 24

Anterior longitudinal ligament

Posterior longitudinal ligament

Question 25

Which parts of the innvertebral disc have innervation? [1]

Answer 25

Lacks innervation in nucleus pulposus **Outer 1/3rd** of **annulus** **fibrosus** innervated

Question 26

Most common hernated discs are found where? [2]

Answer 26

Most commonly IV disc between L4/5 or L5/S1

Question 27

Describe causes of cauda equina syndrome [5]

Answer 27

Cauda equina syndrome is caused by **compression of the cauda equina**: * **Disc herniation** (most common cause) – most commonly occuring at L5/S1 and L4/L5 level * **Trauma** – including vertebral fracture and subluxation * **Neoplasm** – either primary or metastatic The most common cancers that spread to spinal vertebrae are thyroid, breast, lung, renal and prostate * **Infection** – e.g. discitis or Potts disease * **Chronic spinal inflammation** – e.g. ankylosing spondylitis * **Iatrogenic** – e.g. haematoma secondary to spinal anaesthesia

Question 28

Describe the signs / symptoms of cauda equina syndrome [5]

Answer 28

Cauda equina syndrome results in **lower motor neurone signs and symptoms**: * reduced or absent lower extremity reflexes * reduced lower limb sensation (often bilateral) * bladder or bowel dysfunction * lower limb motor weakness * severe back pain * impotence.

Question 29

How do you treat cauda equina syndrome? [2]

Answer 29

Discetomy laminectomy

Question 30

What is a burst facture? [1] Describe immediate [2] and late [1] complications of burst fractures

Answer 30

When a **vertebra is crushed in all directions** **Immediate problems:** * Compression of the spinal cord or nerve roots * Instability **Late problems:** * Haematoma; necrosis

Question 31

Describe how OA can cause compression of vertebral artery? [2]

Answer 31

**Osteophytes** development around **margin of vertebral** body and **zygapophysial** (facet) joints Can block off the flow of the **vertebral artery**

Question 32

OA or degenerative disc disease blocking the vertebral artery caues what pathology? [1]

Answer 32

Vertebral-basilar artery insufficiency

Question 33

Describe pathophsiology of Diffuse idiopathic skeletal hyperostosis (DISH) [2]

Answer 33

**Unilateral** **ossification** of **anterior longitudinal ligament** (+/- osteophytes) **Not complete ossification**: looks like candle wax **Disc height maintained**

Question 34

Classic presentation of ankylosing spondylitis? [2]

Answer 34

Back pain Ankylosing spondylitis is 3 times more frequent in men than in women and begins most often between ages 20 and 40

Question 35

Describe pathophsiology of AS

Answer 35

95% of patients have **HLA B27** **Narrowing and sclerosis** of both **sacroiliac joints** **Sclerosis** and **ankylosis** of **vertebral bodies** with no loss of disc space Bone formation extends across **anterior and lateral margins of IV discs**

Question 36

Describe how HLA B27 is thought to cause ankylosing spondylitis [2]

Answer 36

HLA B27 influences the composition of the endogenous gut flora: * B27 flora predisposes to a **leaky gut** * Leaky gut allows substances that **trigger cascades of inflammatory reactions**

Question 37

Describe how RA has cervical spine invovlement [3]

Answer 37

**Pannus** formation resulting in **bony erosion** and **ligamentous laxity** This cascade can lead to cervical spinal instability in the form of **atlantoaxial instability (AAI)** Also **compression of vertebral arteries**