Lumbar Spine

Question 1

upper motor neuron signs

Answer 1

inc muscle tone (spasticity), weakness, hyperreflexia

Question 2

what is a sign of hyperreflexia

Answer 2

Babinskis sign - big toe is extended rather than flexed upon appropriate stimulation

Question 3

lower motor neuron signs

Answer 3

muscle weakness, wasting (atrophy), absence of reflex

Question 4

how do spinal nerves arise

Answer 4

• begin as anterior (motor) and posterior (sensory) nerve root, arise from spinal cord and unite at intervertebral foramina, forming a single mixed spinal nerve
• The spinal nerve then leaves the vertebral canal via the intervertebral foramina and divides into two:
• The posterior rami supply the nerve fibres to the synovial joints of the vertebral column and the deep muscles of the back, and the anterior rami supply nerve fibres to much of the remaining body (posterior = dorsal). ​

Question 5

where does the mixed spinal nerve splt into posterior and anterior rami

Answer 5

intervertebral foramina

Question 6

Question 7

at what level does the spinal cord end

Answer 7

• L1/2 - tapers off forming the conus medullaris
• the spinal nerves that arise from here are called the cauda equina
• therefore, there is no spinal cord in the lumbosacral spine - problems here tend to arise as nerve root problems not spinal cord injury

Question 8

which nerve root is commonly affected in disc prolapse

Answer 8

• traversing nerve root
• in far lateral disc prolapse the exiting nerve root can be affected

Question 9

how are nerve roots named in the cervical and lumbar spine

Answer 9

In the cervical spine, the nerve root is named according to the lower spinal segment that the nerve root runs between, e.g. nerve at C5-6 level is called C6 nerve root.

In the lumbar spine, the nerve roots are named according to the upper segment that the nerve runs between.

Question 10

what does nerve root compression cause

Answer 10

radiculopathy (pinched nerve) that results in pain down the dermatome of that nerve, and weakness ina ny muscle supplied (myotome) with reduced or absent reflexes

Question 11

what is nerve root compression called in the lower leg

Answer 11

sciatica (L4-S3)

Question 12

sciatica - L3/4 prolapse

Answer 12

(L4 entrapment)

pain down to medial ankle, loss of quadriceps, reduced knee jerk

Question 13

sciatica - L4/5 prolapse

Answer 13

pain down dorsum of foot, reduced power extensor hallicus longus and tibialis anterior

Question 14

sciatica - L5/S1 prolapse

Answer 14

pain to sole of foot, reduced pwoer plantarflexion, reduced ankle jerks

Question 15

what can a very lateral disc prolapse cause

Answer 15

impingement of the exiting nerve root

Question 16

Answer 16

A – laterally placed prolapse affects exiting nerve root (e.g. exiting L4).

B – central prolapse affects traversing nerve root (e.g. traversing L5).

C – central prolapse leads to cauda equina.

D – formation of osteophytes in the lateral canal will also lead to root compression.

Question 17

treatment of disc prolapse

Answer 17

analgesia, maintaing mobility and physio are first line

drugs for neuropathic pain (gabapentin) in severe cases

very occasionally surgery (discectomy)

Question 18

within what time period should disc prolapse resolve

Answer 18

3 months

after this surgery (discectomy) may be considered

Question 19

chance fractures

Answer 19

• seatbelt fractures
• sudden flexion of the vertebral body disrupts the posterior elements
• very unstable and associated with intra-abdominal injuries

Question 20

Answer 20

chance fracture

Question 21

where is lumbar puncture and spinal anaesthesia performed

Answer 21

highest point of iliac crest - L4

Question 22

myelopathy

Answer 22

• describes any neurologic deficit related to the spinal cord
• causes upper motor neuron signs eg Babinski sign

Question 23

babinski sign

Answer 23

the big toe is extended rather than flexed on appropriate stimulation

upper motor neuron symptom

Question 24

spondylosis

Answer 24

broad term meaning degeneration of the spinal column

intervertebral discs lose water content with ageing leading to overloading of the facet joints

most commonly occurs L45 and L5/S1

Question 25

what can spondylosis lead to

Answer 25

secondary OA

Question 26

clinical features of spondylosis

Answer 26

pain when flexing back (weight load on the facet joints) and relief when flexing forward

Question 27

are MRIs diagnostic for bulging discs

Answer 27

no - 60% of people \>45 have bulging discs on MRI

Question 28

mechanical back pain

Answer 28

recurrent relapsing and remitting back pain with no neurological symptoms worse with movement and relieved by rest no red flag symptoms present

Question 29

causes of mechanical back pain

Answer 29

obesity depression poor lifting technique poor posture degenerative disc prolapse OA spondylosis - 2y OA

Question 30

treatment of mechanical back pain

Answer 30

analgesia and physio bed rest not advised small minority of patients benefit from surgery

Question 31

acute disc tear

Answer 31

can occur in the outer annulus fibrosus of the interverterbal disc very painful as it has a rich innervation

Question 32

how does an acute disc tear present

Answer 32

classically patient described lifting heavy object and feeling a twang as their annulus tears pain is worse on coughing

Question 33

where does acute disc tear typically effect

Answer 33

L4/5 or L5/S1

Question 34

how long does it usually take acute disc tear to settle

Answer 34

most by 3 months in the absence of complications surgery musn't be considered until after 3 months management

Question 35

bony nerve root entrapment

Answer 35

OA of the facet joints can result in osteophytes iminging on exiting nerve roots , resulting in nerve root symptoms and sciatica

Question 36

how is bony nerve root entrapment treated

Answer 36

surgical decompression, with trimming of the osteophyte may be performed in suitable candidates

Question 37

spinal stenosis

Answer 37

facet joint OA produces generalised narrowing of the lumbar spinal canal (cauda equina has less space) - **spinal stenosis** multiple nerve roots can be compressed or irritated

Question 38

what can spinal stenosis lead to

Answer 38

neurogenic claudication - bilateral burning pain in legs on walking

Question 39

how does neurogenic claudication differ to vascular claudication

Answer 39

pedal pulses are present claudication distance is inconsistent pain is burning rather than cramping pain is less walking uphill (spine flexes forward creating more space for cauda equina)

Question 40

cauda equina syndrome

Answer 40

the cauda equina is a bundle of nerves, and occasinally a very large central disc prolapse can compress **all** the nerve roots results in a range of signs and symptoms collectively called cauda equina syndrome lower motor neuron lesion

Question 41

how serious is cauda equina

Answer 41

**surgical emergency - discectomy** prolonged compression can cause permanent nerve damage requiring colostomg and urinary diversion urgent discectomy can prevent this

Question 42

main signs of cauda equina syndrome

Answer 42

* incontinence/retention of faeces * reduced anal tone * saddle anaesthesia * bilateral leg pain * paralysis +/- sensory loss ## Footnote ***in essence any patient with bilateral leg symptoms and any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven other wise***

Question 43

management of cauda equina syndrome

Answer 43

PR examination is mandatory urgent MRI to determine the level of prolapse **urgent discectomy**

Question 44

red flag signs of back pain

Answer 44

cauda equina back pain in the younger patients new back pain in the older patients nature of pain - severe, constant, worse at night systemic upset Immuncompromised thoracic pain previous carcinoma structural spinal deformity widespread neurological symptoms

Question 45

describe the pain from tumours

Answer 45

constant, unremitting, severe and worse at night (compare to mechanical back pain)

Question 46

why is new back pain in the older patient a red flag

Answer 46

higher risk of neoplasia, particualrly metastatic disease and multiple myeoma

Question 47

what benign tumours are common in adolescenets

Answer 47

osteoid osteoma

Question 48

what malignant primary bone tumour is common in adolescents

Answer 48

osteosarcoma

Question 49

yellow flags for back pain

Answer 49

Psychosocial factors that are indicative of long term chronicity and disability: * Low mood * High levels of pain/disability * Belief that activity is harmful, low education level * Obesity * Job dissatisfaction * Lot of lifting at work * Problem with claim/compensation (secondary gain)

Question 50

management of back pain

Answer 50

short term - NSAIDs and muscle relaxants physio osteopathy and chiropractic referral

Question 51

osteoperotic crush fracture

Answer 51

with severe osteoperosis (bones less dense due to loss of bone material), spontaenous crush fractures of the vertebral body can occur leading to acute pain and kyphosis minority of patients go on to have chronic pain due to altered spinal mechanisms

Question 52

treatment of osteoperotic crush fractures

Answer 52

usually conservative balloon vertebroplasty for patients with chronic pain has good results but is yet to be fully approved

Question 53

Answer 53

Question 54

name 3 ways in which the cervical vertebra differ

Answer 54

* Triangular vertebral foramen * Bifid spinous process * Transverse foramen * For vertebral artery

Question 55

what action do the atlanto occipital and axial joints allow

Answer 55

Atlanto-occipital joint does nodding action, and atlanto-axial joint allows head rotation.

Question 56

atlas anatomy

Answer 56

no vertebral body or spinous process

Question 57

Answer 57

* note C1 has no spinous process * note dens

Question 58

what type of joints are the vertebral body joints

Answer 58

2y cartilaginous joints

Question 59

what type of joints are the facet joints

Answer 59

synovial

Question 60

why is lumbar rotation less than thoracic

Answer 60

more vertically orientated facet joints

Question 61

paraspinal muscles

Answer 61

located posterolaterally to the spinal column