Fractures of vertebrae
Fractures and fracture-dislocations usually due to sudden forceful flexion. Causes compression fractures of the body of vertebrae.
Vertebrae may become anteriorly displaced on the vertebrae inferior to it. This dislocates and fractures the articular facets and and ruptures interspinous ligaments
Injury of zygapophyseal joints
Damage to facet joints affects related spinal nerves. Causes pain along the distribution of dermatomes and spasm in the muscles of the myotomes (incomplete answer)
What is the frequency of pain experienced in each area of the spine?
Cervical: mobile area of the spine, bears the weight of the head. Pain caused by trauma, fractures or degenerative changes.
Thoracic: Ribcage redistributes weight of the spine, rarely experience stress-related pain. Pain commonly due to pathology e.g. TB, tumour, trauma, infection. Red flag in children
Lumbar: degenerative changes and stress-related pain
Sources of back pain
Damage to muscle: lumbago, fibrositis, fibromyalgia
Damage to bone: fracture, osteoporosis, tumor, infection
Damage to IV discs: prolapse,
Damage to cartilage of the vertebral bodies
Damage/compression of nerve roots (not covered by neurolemma),referred pain
How does IV disc prolapse cause back pain?
IV disc prolapse is more common in younger people because the nucleus polposus is still fluid and mobile.
If the annulus fibrosis degenerates the nucleus polposus herniates posterolaterally and can compress the spinal cord or nerve roots. Posterior roots of the spinal cord do not have a neurolemma, and are therefore more susceptible to damage.
Localised back pain is caused by compression of the longitudinal ligaments and annulus fibrosus, and from local inflammation
Chronic back pain is due to compression of the nerve roots by a herniated disc which is referred to the dermatome
Common causes of lower back pain
Mechanical overuse injury
Degenerative changes in the IV discs - loss of disc height can cause the nerves to be strangled by facet joints
Osteoarthritiis - osteophytes can cause direct pressure on the nerve roots.
Symptoms of degenerative changes in the joints
Stiffness - worse in the mornining or after periods of rest. Movement lubricates the joints
Intermittent pain becoming more constant as the condition progresses
Management of lower back pain
Physiotherapy - postural control
Avoid causative factors
Cognitive therapy (particularly for chronic pain)
Spinal injections (anaesthetics)
Presentation of IV disc prolapse
Prodromal back pain
Muscle spasm (can result in scoliosis)
Pain in the lower back and hip radiating down the back of the thigh to the leg.
Caused by a herniated lumbar IV disc or osteophytes that compress the L5 or S1 component of the sciatic nerve.
Compression causes pain, parasthesia, numbness and can lead to irreparable paralysis of the muscle. This requires surgical intervention.
Rupture of the transverse ligament of atlas
Rupture of the transverse ligament means that the odontoid process is free, resulting in dislocation of the atlas and axis. The odontoid process may be driven into the upper cervical region of the spinal cord causing quadriplegia, or into the brainstem causing death
Examination in a patient with sciatica
Neurological examination: sensation
Reflexes - lost if the nerve is compressed
Straight leg raising sign
Injury of the ligamenout tissue of the back. Results from excessively stong contractions in extension or rotation of the back.
Back strain involves stretching or tearing of muscle fibres. Caused if weight is not properly distributed on the vertebral column.
Mangement of patiens with sciatica
Disc removal if there are neurological problems
Central disc prolapse
Common in L4/L5 vertebrae
Damages sacral plexus
Results in impotence, incontinence, loss of anal tone on PR exam (red flags)
Cauda equina syndrome
Compression arising from a large central disc herniation at L4/L5 or L5/S1 vertebral level, tumours, trauma or spondylolisthess
Damages sacral plexus
Incontinence, Impotence, Sensory changes in perineum, back pain, (asymmetrical) lower limb weakness, loss of reflexes
Assess using MRI
Narrowing of the spinal canal with resulting pressure on the cauda equina
Due to osteophytes and thickening of the ligamentum flava with age spinal canal is narrowed.
Venous return to the lower limbs increases during exercise, some is redirected to the spinal plexus if return to the IVC is impaired. This further reduces the space in the spinal canal, impinging on the nerves and causing pain.
Anterior displacement of thevertebral body relative vertebrae below
Due to degenerative changes in the facet joints or pars interarticularis fractures
If it occurs in L5 vertebrae can cause compression of the cauda equina as they pass into the superior part of the sacrum, causing back and lower limb pain.
In C2 (Hangman's fracture)
Pars interarticularis fractures
Fracture of the vertebra between the superior and inferior facet joints.
Vertebral body may slip anteriorly and compress the vertebral canal.
Common at L4 and L5
Osteoporosis in the spine
Bones become weakened and brittle, so are more subject to fractures.
Increase in thoracic kyphosis due to compression of the anterior part of the vertebral body which causes progressive erosion and collapse of the vertebrae