Lumbar Spine

Question 1

What is ‘mechanical back pain’

Answer 1

recurrent relapsing and remitting back pain that involves no neurological symptoms

Question 2

presentation of mechanical back pain

Answer 2

worse on movement (mechanical) and relieved by rest

Question 3

“red flag” symptoms in mechanical pain

Answer 3

There are none!!

Question 4

age group that tends to be affected by mechanical back pain

Answer 4

20-60 years

Question 5

causes of mechanical back pain

Answer 5

obesity 
lack of exercise 
poor lifting technique 
depression 
degenerative disc prolapse
facet joint OA 
spondylosis

Question 6

Tx of mechanical back pain

Answer 6

analgesia

physiotherapy

Question 7

is bed rest advised for mechanical back pain

Answer 7

No!

leads to stiffness and spasm which exacerbates symptoms

Question 8

do patients with mechanical back pain tend to have single level disease or multi level disease

Answer 8

multi level disease

Question 9

what type of patient would be suitable for spinal stabilisation surgery for mechanical back pain

Answer 9

single level disease which hasn’t improved with physio and analgesia, and there is no claim/compensation involved

Question 10

sections of an intervetebral disc

Answer 10

outer annulus fibrosis

inner nucleus pulposus

Question 11

what is an acute disc tear

Answer 11

a tear of the outer annulus fibrosis of the IV disc

Question 12

cause of an acute disc tear

Answer 12

typically after lifting a heavy object

Question 13

why is an acute disc tear very painful

Answer 13

the periphery of the IV disc is richly innervated

Question 14

presentation of an acute disc tear

Answer 14

history of heavy lifting
sudden onset
pain +++
pain worse on coughing

Question 15

Tx acute disc tear

Answer 15

analgesia

physiotherapy

Question 16

Ix for acute disc tear

Answer 16

Erect lumbar spine xray

Question 17

When is an erect lumbar spine xray the preferred imaging modality

Answer 17

recent significant trauma
osteoporosis
age >70

Question 18

When is lumbar MRI the preferred imaging modality

Answer 18

spinal malignancy 
infection 
fracture 
cauda equina syndrome 
ank spond or other inflammatory cause

Question 19

What is sciatica

Answer 19

Clinical symptoms that result from compression of the L4, L5, S1 nerve roots. Compression is due to IV disc material that herniates through a tear in the IV disc and impinges on an exiting nerve root.

Causes pain and altered sensation in a dermatomal distribution and reduced power in a myotomal distribution

Question 20

Symptoms of sciatica

Answer 20

radicular pain felt as neuralgic burning or tingling sensation, that radiates down the back of the thigh and below the knee

Question 21

symptoms of an L3/L4 disc prolapse

Answer 21

L4 nerve root entrapment
pain down to the medial ankle (L4)
loss of quadriceps power
reduced knee jerk

Question 22

symptoms of an L4/L5 disc prolapse

Answer 22

L5 root entrapment
pain down dorsum of foot
reduced power of Extensor Hallucis longus and tibialis anterior

Question 23

symptoms of an L5/S1 disc prolapse

Answer 23

S1 root entrapment
pain to sole of foot
reduced power plantarflexion
reduced ankle jerks

Question 24

Tx of disc prolapse/sciatica

Answer 24

analgesia and physiotherapy

Question 25

Generally how long does an acute disc tear/prolapse/sciatic symptoms take to settle

Answer 25

70% settle in 3 months | 90% settle in 18-24 months

Question 26

What surgery is considered for disc prolapse and when is it considered

Answer 26

Discectomy - pain is not resolving despite physio and there are localising signs suggesting a specific nerve root involvement and positive MRI evidence of nerve root compression

Question 27

What causes bony nerve root entrapment in the lumbar spine

Answer 27

``` Bone growth (osteophytes) that occurs in OA. The osteophytes can impinge on exiting nerve roots and cause symptoms of sciatica ```

Question 28

Tx of bony nerve root entrapment

Answer 28

Surgical decompression and trimming of osteophytes

Question 29

what is spondylosis

Answer 29

loss of water content of IV discs with age

Question 30

consequences of spondylosis

Answer 30

less cushioning increased pressure on facet joints secondary OA

Question 31

what is spinal stenosis

Answer 31

narrowing of the spinal canal or neural foramina, producing nerve root compression, root ischaemia and a variable syndrome of back and leg pain

Question 32

causes of spinal stenosis

Answer 32

several - anything disease process that can narrow the space spondylosis bulging discs osteophytosis

Question 33

how is spinal stenosis/claudication differentiated from vascular claudication due to PVD

Answer 33

the claudication distance is inconsistent the pain is burning rather than cramping pain is less walking uphill (spine flexion creates more space for the cauda equina) pedal pulses are preserved

Question 34

Mx of spinal stenosis

Answer 34

conservative Mx - weight loss, physio

Question 35

what is cauda equina syndrome

Answer 35

a clinical syndrome resulting from a very large central disc prolapse, which compresses all the nerve roots of the cauda equina.

Question 36

why is cauda equina syndrome a surgical emergency

Answer 36

affected nerve roots include the sacral roots S4/S5 which control defecation and urination. prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion

Question 37

clinical features of cauda equina syndrome

Answer 37

bilateral leg pain "saddle anaesthesia" - perineal numbness altered urinary function - urinary retention or incontinence faecal incontinence and constipation

Question 38

Ix for cauda equina syndrome

Answer 38

PR exam - mandatory urgent MRI

Question 39

Tx cauda equina syndrome

Answer 39

urgent discectomy

Question 40

red flags of back pain

Answer 40

1. back pain in young patient (<20 years) 2. new back pain in older patient (>60 years) 3. constant severe pain worse at night 4. systemic upset 5. history of cancer

Question 41

in terms of lumbar spine, what is the risk for severe osteoporotic patients

Answer 41

osteoporotic crush # - basically the vertebrae cant be supported and all crush together

Question 42

symptoms of osteoporotic crush #

Answer 42

acute pain | kyphosis

Question 43

Mx of osteoporotic crush #

Answer 43

conservative Mx