Mechanical Spinal Problems

Question 1

what are the causes of lower back problems?

Answer 1

• Mechanical back pain.
• Lumbar disc herniation.
• Cauda equina.
• Lumbar stenosis.
• Malignancy.
• Trauma.
• Infection, e.g. tuberculosis.

Question 2

what are the common causes of mechanical back pain?

Answer 2

obesity, lack of exercise, strain on paraspinal muscles, facet joint osteoarthritis

Question 3

what are the clinical features of mechanical back pain?

Answer 3

morning stiffness which resolves with movement.

Pain is made worse by prolonged sitting or when rising from a seated position

Question 4

what occurs with facet joint hypertrophy?

Answer 4

referred pain from the nerve supplying the facet joint that mimics sciatica; but does not radiate below the knee.

Question 5

what are the red flag features of low back pain?

Answer 5

• Age: >60 or <20 years old
• Pain not improved by rest
• Pain that wakes the patient up at night
• Urinary retention/incontinence and faecal incontinence
• Saddle anaesthesia
• History of malignancy
• Unexplained weight loss.
• Night sweats, Fever, immunosuppression or IV drug abuse
• Progressive neurological deficit
• Trauma

Question 6

what is the pathophysiology of a lumbar disc herniation?

Answer 6

occurs when the nucleus herniate through a tear in the annulus ring and compress adjacent nerve roots

Question 7

which nerve roots are affected in lumbar disc herniation?

Answer 7

L4/5 level and L5/S1

Question 8

what are the different directions of vertebral disc prolapse?

Answer 8

posterolateral/paramedian
far lateral/extraforaminal
central/medial

Question 9

which nerve is affected in posterolateral herniated discs?

Answer 9

traversing nerve (the nerve root that exits below the level of prolapsed disc)

Question 10

which nerve is affected in far lateral herniated discs?

Answer 10

exiting nerve (the nerve root that exits at the level of the prolapse)

Question 11

what could central/medial herniated discs result in?

Answer 11

lumbar stenosis or cauda equine

Question 12

what is the definition of radiculopathy?

Answer 12

dysfunction of a nerve root causing a dermatomal sensory deficit with weakness of the muscle groups supplied by that nerve

Question 13

what is the definition of sciatica?

Answer 13

pain along the sciatic nerve usually due to compression of nerve roots L4 – S3)

Question 14

what are the general features of lumbar disc herniation?

Answer 14

o Sciatic pain pattern
o Numbness or tingling sensations along the distribution of the affected nerve.
o Weakness.
o Straight leg raise test positive

Question 15

what are features of sciatic pain?

Answer 15

Shooting pain radiating from the buttocks down to the posterior knee/leg. The pain can be exaggerated by coughing or sneezing.

Question 16

what are the clinical features of a L5/S1 prolapsed intervertebral disc?

Answer 16

o Pain along the posterior thigh with radiation to the heel.
o Weakness of plantar flexion
o Sensory loss in the lateral foot.
o Reduced or absent ankle jerk.

Question 17

what are the clinical features of a L4/L5 prolapsed intervertebral disc?

Answer 17

o Pain along the posterior/posterolateral thigh, radiating to dorsum of the foot and great toe.
o Weakness of dorsiflexion of the toe or foot.
o Paraesthesia and numbness of the dorsum of the foot and great toe.
o Reflex changes unlikely.

Question 18

what are the clinical features of a L3/L4 prolapsed intervertebral disc?

Answer 18

o Pain in the anterior thigh.
o Wasting of the quadriceps muscle.
o Weakness of the quadriceps function and dorsiflexion of foot.
o Diminished sensation over anterior thigh, knee and medial aspect of lower leg.
o Reduced knee jerk.

Question 19

what are the indications for surgery in lumbar disc prolapses?

Answer 19

• Failure of conservative treatment - First line management
• Pain
• Central disc prolapse: Patients with bilateral sciatica or features indicating a central disc prolapse, such as sphincter disturbance and diminished perineal sensation, should be investigated promptly.
• Tumour
• Neurological deficits

Question 20

what are the clinical features of spinal claudication?

Answer 20

Usually intermittent
Worse on mobilising
Eases at rest + bending forwards
Pain often back of thighs/calves
Altered sensation
Heaviness/weakness
Spinal vs vascular claudication

Question 21

how does cauda equina occur?

Answer 21

compression of the cauda equine of the spinal cord

Question 22

what are the causes of cauda equina?

Answer 22

• Prolapsed lumbar disc: usually a midline herniation commonly at L4/5
• Tumour compression.
• Trauma.
• Infection
• Hematoma.

Question 23

what are the clinical features of cauda equina?

Answer 23

urinary retention
saddle paraesthesia
incontinence
low back pain
bilateral sciatic leg pain - radicular pain in both legs along with complete or partial loss of motor and sensory function

Question 24

what investigations should be done in cauda equina?

Answer 24

• MRI lumbosacral spine and a digital rectum examination

Question 25

cauda equina...

Answer 25

a neurosurgical emergency

Question 26

what is the management of cauda equina?

Answer 26

herniated disc --> discectomy fracture --> decompression +\- fixation hematoma --> evacuation

Question 27

what is spinal stenosis?

Answer 27

narrowing of the spinal canal

Question 28

what part of the spinal cord is affected in lumbar spinal stenosis?

Answer 28

conus medullaris | L4/5, L3/4

Question 29

what are the causes of lumbar spinal stenosis?

Answer 29

* hypertrophy of facets joints and ligamentum flavum * protruding intervertebral discs * spondylolisthesis

Question 30

what are the clinical features of lumbar spinal stenosis?

Answer 30

slow onset Unilateral or bilateral hip, buttocks or lower extremity pain or burning sensation Neurogenic intermittent claudication: leg weakness, tingling and numbness

Question 31

what are the precipitating and relieving factors of lumbar spinal stenosis?

Answer 31

precipitated by standing or back extension and relieved by sitting, lumbar flexion or walking uphill

Question 32

what is the distribution of pain in neurogenic claudication?

Answer 32

Dermatomal

Question 33

what is the distribution of pain in vascular claudication?

Answer 33

Sclerotomal (muscle group with same vascular supply)

Question 34

what are the exacerbating factors of neurogenic claudication?

Answer 34

* Exercise: variable amount of exercise can elicit the pain (distance is inconsistent) * Prolonged standing at rest

Question 35

what are the exacerbating factors of vascular claudication?

Answer 35

* Exercise: pain can be reproduced with a fixed amount of exercise or distance * Rare at rest

Question 36

what are the relieving factors of neurogenic claudication?

Answer 36

* Resting: often slow (>30 mins) | * Posture: relieved on walking uphill, sitting, waist flexion

Question 37

what are the relieving factors of vascular claudication?

Answer 37

* Resting: immediate relief | * Posture: not dependent on posture or position.

Question 38

what type of pain is in neurogenic claudication?

Answer 38

Burning

Question 39

what type of pain is in vascular claudication?

Answer 39

Cramping

Question 40

are there any changes to peripheral pulses in neurogenic claudication?

Answer 40

Normal

Question 41

are there any changes to peripheral pulses in vascular claudication?

Answer 41

Diminished or absent

Question 42

what are the causes of failed back syndrome?

Answer 42

* Recurrence, residual compression * Nerve injury * Altered joint mobility * Instability * Fibrosis, arachnoiditis * Infection * Depression, anxiety * Diabetes * Smoking * BMI

Question 43

what is the management of failed back syndrome?

Answer 43

* Difficult * Recurrence - ?re-operation * Infection - Antibiotics * Anti-inflammatories * Physiotherapy * Behavioural therapy * TENS * Antidepressants * Spinal cord stimulation * Intrathecal pump

Question 44

what is cervical spondylosis?

Answer 44

degenerative arthritic process involving the cervical spine and affecting the intervertebral disc and zygapophyseal joints

Question 45

how can cervical spondylosis present?

Answer 45

degenerative cervical myelopathy (UMN signs) or radiculopathy (LMN signs).

Question 46

what changes to the cervical discs occur in cervical spondylosis?

Answer 46

degeneration process causes stress on the articular cartilages of the vertebral end-plates. Osteophytic spurs develop around the margins of the disintegrating end-plates. These spurs can grow posteriorly into the spinal canal and anteriorly into the prevertebral space.

Question 47

what are the clinical features of cervical spondylosis?

Answer 47

radiculopathy neck pain myelopathy

Question 48

what are the radiological features of cervical spondylosis?

Answer 48

* Narrowing of the disc space - C5/C6 and C6/C7 | * Osteophyte formation

Question 49

what is the management of cervical spondylosis?

Answer 49

decompressive cervical laminectomy anterior cervical discectomy posterior cervical foraminotomy

Question 50

what is myelopathy?

Answer 50

spinal cord compression which causes UMN signs

Question 51

what are the clinical features of Degenerative Cervical myelopathy?

Answer 51

* Imbalance and disturbance of gait which can lead to falls * “Numb, Clumsy hands” with difficulty holding a fork or buttoning shirt * Finger-tip paraesthesia * Urinary or faecal incontinence (rare). * Pain in a non-dermatomal distribution * Legs jump at night due to hyperreflexia * Weakness, hyperreflexia and spasticity, brisk reflexes in legs (upgoing plantars) * Positive Babinski and Hoffman's signs. * Loss of dexterity using fingers – difficulty with fine motor tasks, dropping objects

Question 52

what is the gold standard investigation for Degenerative Cervical myelopathy?

Answer 52

MRI

Question 53

what are the MRI features of cervical myelopathy?

Answer 53

disc degeneration, ligament hypertrophy +/- spinal cord signal change