Clinical conditions of the back Flashcards
(74 cards)
1
Q
What is mechanical back pain characterised by?
A
- Pain when the spine is loaded
- Worsens with exercise and is relieved with rest
- Intermittent
- Often triggered by innocuous activity
2
Q
What are the risk factors for mechanical back pain?
A
- Obesity
- Poor posture
- Sedentary lifestyle
- Deconditioning of paraspinal muscles
- Poorly-designed seating
- Incorrect manual handling techniques
3
Q
Describe disc degeneration in the spinal cord?
A
- Nucleus pulposus of the intervertebral discs dehydrates with age
- Leads to a decrease in the height of the discs, bulging of the discs and alteration of the load stresses on the joints
4
Q
What does degeneration of the discs lead to?
A
- Osteophytes called syndesmophytes develop adjacent to the end plates of the discs
- This is called marginal osteophytosis
- Osteoarthritic changes can develop - this can be painful
5
Q
What happens as vertebral disc height decreases and arthritis develops?
A
- Compression of the spinal nerves
- Perceived as radicular or nerve pain
6
Q
What happens as vertebral disc height decreases and arthritis develops?
A
- Compression of the spinal nerves
- Perceived as radicular or nerve pain
7
Q
What are the four stages of disc herniation?
A
- Disc degeneration: chemical changes associated with ageing causes disc to dehydrate and bulge
- Prolapse: protrusion of nucleus pulposus occurs with slight impingement into the spinal canal
- Extrusion: the nucleus pulposus breaks through the annulus fibrosus but is still contained within the disc space
- Sequestration: nucleus pulposus separates from the main body of the main body of the disc and enters the spinal canal
8
Q
What are the most common sites for slipped disc?
A
- L4/5
- L5/S1
- Due to mechanical loading at these joints
9
Q
Where are the nerve roots most vulnerable?
A
- Where they cross the intervertebral disc
- When they exit the spinal canal in the intervertebral foramen
10
Q
What is a paracentral prolapse?
A
- Nucleus pulposus herniates posterolaterally
- Causes compression of a spinal nerve root within the intervertebral foramen
- Traversing nerve root is at risk (i.e. if L4/L5 disc is affected, L5 nerve root is compressed)
11
Q
What does a central herniation carry a risk of?
A
- Cauda equina syndrome
12
Q
What is sciatica?
A
- Pain caused by irritation or compression of one or more of the nerve roots that contribute to the sciatic nerve
- L4, L5, S1, S2 and S3
- Causes include marginal osteophytosis, slipped disc etc.
13
Q
What is the pain experienced in sciatica like?
A
- Pain experienced is typically experienced in the back and buttock
- Radiates to dermatome supplied by the affected nerve root
- Paraesthesia is only experienced in affected dermatome
14
Q
What is the typical distribution of pain in sciatica?
A
- L4 sciatica: anterior thigh, anterior knee, medial leg
- L5 sciatica: lateral thigh, lateral leg, dorsum of foot
- S1 sciatica: posterior thigh, posterior leg, heel, sole of foot
15
Q
What are some causes of cauda equina syndrome?
A
- Tumours affecting vertebral column or meninges
- Spinal infection
- Abscesses
- Vertebral fracture
- Spinal haemorrhage
- Ankylosing spondylitis
16
Q
What are the red flag symptoms of cauda equina syndrome?
A
- Bilateral sciatica
- Perianal numbness
- Painless urinary retention
- Urinary/faecal incontinence
- Erectile dysfunction
17
Q
How do we treat cauda equina syndrome?
A
- Surgical decompression within 48 hours of the onset of sphincter symptoms, otherwise prognosis is poor
18
Q
What is spinal canal stenosis?
A
- Abnormal narrowing of the spinal canal that compresses either the spinal cord or nerve roots
19
Q
What are some causes of spinal canal stenosis?
A
- Combination of disc bulging, facet joint osteoarthritis, ligamentum flavum hypertrophy
- Compression fractures of the vertebral bodies
- Spondylolisthesis
- Trauma
20
Q
What are the symptoms of spinal canal stenosis?
A
- Discomfort whilst standing
- Discomfort or pain in the shoulder, arm or hand (cervical stenosis) or in the lower limb (lumbar stenosis)
- Bilateral symptoms
- Numbness at or below the level of stenosis
- Weakness at or below the level of stenosis
- Neurogenic claudication
21
Q
What are the most common forms of stenosis?
A
- Lumbar stenosis
- Cervical stenosis
22
Q
What is neurogenic claudication?
A
- It is a symptom rather than a diagnosis
- Patient reports pins and needles/pain in the legs on prolonged standing and on walking, radiating in a sciatica distribution
- Also feels a cramping pain or weakness in the legs
23
Q
What does neurogenic claudication result from?
A
- Compression of the spinal nerves as they emerge from the lumbosacral spinal cord
- Results in reduced arterial inflow to nerves and transient arterial ischaemia
- Results in pain or paraesthesia
24
Q
What relieves neurogenic claudication?
A
- Rest
- A change in position
- Flexion of the spine
25
What is spondylolisthesis?
- Anterior displacement of the vertebra above relative to the vertebra below
26
What is spondylolisthesis associated with?
- Gross instability of the spinal column
27
What are the symptoms of spondylolisthesis?
- Some individuals may be asymptomatic
- Most complain of some discomfort ranging from occasional lower backpain to incapacitating mechanical pain, sciatica from nerve root impression, and neurogenic claudication
28
How do we treat spondylolisthesis?
- Surgically using screws and rods to stabilise the spine
29
What is the method for spotting spondylolysis?
- Scottie dog seen in oblique views of the spine
- If the dog's head is detached from the body, indicating that spondylolisthesis has occurred
30
Where is a lumbar puncture needle inserted?
- In the midline between the spinous processes of the L3 and L4 (or L4 and L5) vertebrae
31
What is cervical spondylosis?
- Chronic degenerative osteoarthritis affecting the intervertebral joints in the cervical spine
32
What is the primary pathology of cervical spondylosis?
- Usually age-related disc degeneration
- Followed by marginal osteophytosis
- Facet joint osteoarthritis
33
What causes radiculopathy during cervical spondylosis?
- Narrowing of intervertebral foramina cab put pressure on spinal nerves
34
What are the symptoms of radiculopathy?
- Dermatomal sensory symptoms (e.g. paraesthesia and pain)
- Myotomal motor weakness
35
What causes myelopathy during cervical spondylosis?
- If the degenerative process leads to narrowing of the spinal canal, this may put pressure on the spinal cord leading to myelopathy
36
How does myelopathy present?
- Global muscle weakness
- Gait dysfunction
- Loss of balance
- Loss of bowel/bladder control
37
Why do symptoms of myelopathy arise?
- Due to compression and dysfunction of the ascending and descending tracts within the spinal cord
38
What is a Jefferson's fracture?
- Fracture of the anterior and posterior arches of the atlas vertebra (C1)
- Causes C1 vertebra to burst open like a polo mint
39
What is the mechanism of injury of a Jefferson's fracture?
- Axial loading e.g. diving into shallow water
40
What are the symptoms of a Jefferson's fracture?
- Pain but no neurological signs
- Occasionally may be damage to the arteries at the base of the skull leading to secondary neurological sequelae e.g. ataxia, stroke or Horner's syndrome
41
What is a Hangman's fracture?
- The axis vertebra (C2) is fractured through the pars interarticularis
- Unstable and requires treatment
42
What is the mechanism of injury of a Hangman's fracture?
- Forcible hyperextension of the head on the neck
- Road traffic collisions
43
What can cause fractures of the odontoid process?
- Can be caused by either flexion or extension injuries
- Most commonly seen mechanism is an elderly patient with osteoporosis falling forwards and hitting their forehead (hyperextension)
- Can also be caused by a blow to the back of the head resulting in a hyperflexion injury
44
How do we detect an odontoid process fracture?
- Detected on an open mouth AP X-ray or a CT of the cervical spine
45
What is whiplash?
- Forceful hyperextension-hyperflexion injury of the cervical spine
46
What is the classical mechanism of a whiplash injury?
- A patient's car is struck from the rear leading to an acceleration-deceleration injury
- Hyperextension and hyperflexion leads to tearing of cervical muscles and ligaments
- Secondary oedema, haemorrhage and inflammation may occur
- Spasm causes pain and stiffness
47
What else may patients with whiplash injury present with?
- Pain and paraesthesia as a result of injury to the spinal nerves during the whiplash movement of the cervical spine.
- Patients may also develop shoulder injuries and lower back pain acutely
48
How can some whiplash injuries result in injury to the cervical cord?
- Cervical spine is highly mobile and the ligaments and capsule of the joints are weak and loose
- There can be significant movement of the vertebrae at the time of impact
49
What is a protective factor against cervical spinal cord injury?
- Vertebral foramen is large relative to the diameter of the cord
50
What makes a cervical intervertebral disc prolapse more likely to be painful?
- There is little space available for the exiting nerves
- So even a small cervical disc herniation may impinge on the nerve and cause significant pain
51
What can cause cervical intervertebral disc prolapse?
- May be spontaneous
- May be related to trauma and neck injury
52
What are the symptoms of cervical intervertebral disc prolapse?
- Paracentral prolapse may impinge on a spinal nerve leading to radiculopathy
- Canal filling prolapse may lead to acute spinal cord compression
- Symptoms are dependent on the site of the prolapse
- Exiting nerve root is compressed
53
What is cervical myelopathy?
- Spinal cord dysfunction due to compression of the cord
- Caused by narrowing of the spinal canal
54
What is common cause of cervical myelopathy?
- Degenerative stenosis of the spinal canal caused by cervical spondylosis
- Most commonly affects 50-80 years old
55
What is the cause of cervical spondylotic myelopathy?
- Degenerative changes that develop with age, including:
- Ligamentum flavum hypertrophy or buckling
- Facet joint hypertrophy
- Disc protrusion
- Osteophyte formation
- These changes cause a reduction in canal diameter, compressing the spinal cord
56
What are some other causes of cervical myelopathy?
- Congenital stenosis stenosis of the spinal canal
- Cervical disc herniation
- Spondylolisthesis
- Trauma
- Tumour
- Rheumatoid arthritis
57
What causes the symptoms of cervical myelopathy?
- Compression of the long tracts of the spinal cord
58
What is the classical presentation of cervical myelopathy?
- Loss of balance with poor coordination
- Decreased dexterity
- Weakness
- Numbness
- Severe cases can lead to paralysis
- Pain may or may not be present
59
How does cervical myelopathy affect elderly patients?
- Cervical myelopathy often manifests with a rapid deterioration of gait and hand function
60
What do upper cervical lesions cause?
- Loss of manual dexterity
- Difficulties writing
- Non-specific alteration in arm weakness and sensation
- May demonstrate dysdiadochokinesia
61
What do lower cervical lesions cause?
- Spasticity
- Loss of proprioception in the legs
- 'Legs feel heavy'
- Reduced exercise tolerance
- Gait disturbance
- May suffer multiple falls
62
What is the usual function of the long tracts?
- Dampen spinal reflexes so a person does not overreact to stimuli
63
What happens when the long tracts are damaged?
- Protective capabilities are less effective
- Patient may demonstrate an exaggerated response to stimulation
- Positive Hoffman's or Babinski sign
64
What is Hoffman's test?
- Doctor holds patient's middle finger at middle phalanx and flicks the finger nail
- If index finger and thumb move, the patient has a positive Hoffman's sign
65
What is the Babinski sign?
- Stroke lateral side of sole of foot with a blunt instrument from the heels to the toes
- Normal response is plantarflexion of toes
- Abnormal/positive Babinski sign = hallux dorsiflexion and toes fan out
- This suggests damage to the long tracts of the spinal cord
66
What happens when spinal cord compression is severe in late cervical myelopathy?
- If surgical decompression is not performed
- Symptoms may progress to sphincter dysfunction and quadriplegia (paralysis of all four limbs)
67
What happens if a patient develops myelopathy of the cervical spine at the level of C5?
- Neck pain
- Weakness of shoulder abduction and external rotation (C5 myotome)
- Weakness of all myotomes distally, including the trunk and the lower limbs
- Paraesthesia from the shoulder distally, trunk and lower limbs
68
What are the commonest causes of thoracic cord compression?
- Vertebral fractures
- Tumours in the spinal canal - metastases are very common
69
What are the symptoms of thoracic cord compression?
- Pain at the site of the lesion
- Spastic paralysis of the leg muscles
- Weakness of intercostal muscles below the level of the lesion
- Paraesthesia in the dermatomes distal to the site of cord compression
- Loss of sphincter control
70
How can pathogens reach the bones and tissues of the spine?
- Haematogenous (most common route)
- Direct inoculation during invasive spinal procedures
- Spread from adjacent soft tissue infection
71
Who is most commonly affected by spondylodiscitis?
- Immunocompromised patients e.g. those with diabetes, HIV and patients on steroids
72
How does infection spread to the intervertebral discs via the blood?
- Discs are avascular
- Organisms are initially deposited in vertebral body via its segmental artery
- Leads to bony ischaemia and infarction
- Necrosis of the bone then allows direct spread of organisms into the adjacent disc space, epidural space and adjacent vertebra bodies
73
How does spread of infection into the spinal canal lead to neurological damage?
- Septic thrombosis leading to ischaemia
- Compression of neural elements by abscess/inflammatory tissue
- Direct invasion of neural elements by inflammatory tissue
- Mechanical collapse of bone leading to instability, particularly in chronic infections
74
What are the common organisms that cause vertebral osteomyelitis/spondylodiscitis?
- Staphylococcus aureus
- Gram negative bacilli such as E. coli
- Coagulase negative Staphylococci (Staph epidermis) common following invasive spinal procedures
- Infection with more unusual organisms (e.g. Pseudomonas, Candida) may be seen in IV drug users
