Mini Symposium: Spine (Degeneration, Low Back Pain, Disc Prolapse)

Question 1

What type of disc protrusion causes cauda equina syndrome?

Answer 1

Central disc protrusion

Question 2

What type of joints are intervertebral discs?

Answer 2

Secondary cartilagenous

Question 3

What are the components of the intervertebral discs?

Answer 3

Annulus fibrosus iis the though outer layer

Nucleus pulposus is the gelatinous core

•Annulus may tear and nucleus prolapse

–Can cause cord / nerve root compression

Question 4

What connects the discs with the vertebral bodies?

Answer 4

The ALL and the PLL

Question 5

• The fibres of the annulus fibrosis (collagen) run obliquely and alternately between layers
• They resist rotational movements
• Discs fail with twisting movements

Question 6

What is the nucleus pulposus made up of?

Answer 6

Mainly of water

and collagen and proteoglycans (very hydrophilic)

Question 7

The disc is kidney bean shaped - what dircetion are disc prolapses usually?

Answer 7

Usually posterolateral

Question 8

What is the normal ageing process of the intervertebral discs?

Answer 8

Water content decreases, disc space is narrowed. This process is usually increased by smoking

Question 9

What are the possible courses of pathology after the annulus fibrosis has been torn and the nucleus pulposus starts to protrude outwards?

Answer 9

Nerve root compression by osteophytes

Central spinal stenosis

Abnormal movement: spondylolysis - (this is a stress fracture of the pars interarticularis of the vertebral arch)

Spondylolisthesis - The displacement of one vertebra in relation to another

Question 10

What are the key features of radiculopathy?

Answer 10

Limb pain is worse than back pain

Pain in a nerve root distribution

Question 11

What is the therapy for nerve root pain?

Answer 11

• Most will settle, about 90% in 3 months
• Physiotherapy
• Strong analgesia
• Referral after 12 weeks
• Imaging

–MRI

Question 12

What are the different classification of slipped disc?

Answer 12

Bulge

Protrusion - annulus is weakened but still intact

Extrusion Through annulus but in continuity

Sequestration - dessicated disc material free in canal

Question 13

What is the most ocmmonly affected disc prolapse in the cervical spine?

Answer 13

Most commonly the C5/C6 disc

Question 14

What percentage of slipped discs are thoracic slippled discs?

Answer 14

Less than 1%

They are mid to lower levels (most are at the T11 - T 12 part)

Herniations are central, posterolateral and lateral

Question 15

Where are the common places for lumbar herniations?

Answer 15

•Usually L4/5 (45%), followed by L5/S1 (40%), then L3/4 (10%)

Most prolapses are posterolateral (posterior longitudinal ligament is the weakest)

Central dis may give pain in both legs, or may be back pain only

Question 16

Which nerve root and disc are associated with the following clinical picture?

Sensory loss: Little toe and sole of foot

Motor weakness: Plantar flexion of foot

Reflex change: Ankle jerk

Answer 16

Disc - L5/S1

Nerve root - S1

Question 17

Which nerve root and disc are associated with the following clinical picture?

Sensory loss - great toe and first dorsal web space

Motor weakness - EHL

Reflex change - none

Answer 17

Disc - L4/L5

Nerve root - L5

Question 18

Which nerve root and disc are associated with the following clinical picture?

Sensory loss - medial aspect of lower leg

Motor weakness - quads

Reflex change - knee jerk

Answer 18

Disc - L3/L4

Nerve root - L4

Question 19

What is the management of suspected cauda equina?

Answer 19

Urgent MRI

Emergency surgery within 48 hours - delay results in permanent dysfunction

•sacral nerve roots compressed – can result in permanent bladder and anal sphincter dysfunction and incontinence

Question 20

What are the common causes of cauda equina syndrome?

Answer 20

–central lumbar disc prolapse (commonest)

–tumours

–trauma (burst or Chance #, disc) or spinal stenosis

–infection (epidural abscess)

–iatrogenic (spinal surgery or manipulation, spinal epidural injection)

Chance fracture results from excessive flexion of the spine and is frequently unstable

Question 21

What are the clinical features of cauda equina syndrome?

Answer 21

–Injury or precipitating event

–Location of symptoms (bilat buttock & leg pain + varying dysaethesiae + weakness – beware)

–Bowel or bladder dysfunction (urinary retention +/- incontinence overflow)

–PR exam - saddle anaesthesia (perianal loss of sensation), loss of anal tone & anal reflex

–High index of suspicion in spinal post-op patients with increasing leg pain in presence of urinary retention

Question 22

What is the investigation for cauda equina if MRI is contraindicated?

Answer 22

Lumbar CT myelogram

Question 23

What are the potential outcomes for cauda equina syndrome?

Answer 23

After discoectomy still cases of:

Abnormal urinary function

Motor deficits

Sensory deficits

Perianal parasthesiae

Persistent sexual dysfunction

Question 24

Where does the degeneration of cervical and lumbar spondylosis occur?

Answer 24

Facet joints

Discs

Ligaments

Spondylosis is referred to as arthritis of the spine

Question 25

What are the outcomes of spondylosis?

Answer 25

Compression of nerve roots as well as the entire spinal cord (myelopathy) Signs of myelopethy are UMN (increased tone, brisk reflexes)

Question 26

Where do you find the posterior longitudinal ligament?

Answer 26

Inside the vertebral canal along the backs of the vertebral bodies

Question 27

What ligament links the lamina?

Answer 27

Ligamentum flavum

Question 28

What is the name of the ligmant that links the transverse processes?

Answer 28

Intertransverse ligament

Question 29

When is neurogenic claudication common?

Answer 29

Lumbar spinal stenosis Causes impingement or inflammation of the nerves leaving the spinal cord

Question 30

What are features of spinal claudication?

Answer 30

–Usually bilateral –Sensory dysaesthesiae –Poss weakness (drop foot – tripping) –Takes several minutes to ease after stopping walking –Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle Neurogenic claudication may present in one or both legs and usually presents as some combination of discomfort, pain, numbness and weakness in the calves, buttocks, and/or thighs. In some patients, it is precipitated by walking and prolonged standing. The pain is classically relieved by a change in position or flexion of the waist

Question 31

What are the types of spinal stenosis?

Answer 31

Lateral recess stenosis - where the disc prolapse most commonly affects the nerve Central stenosis Foraminal stenosis

Question 32

What is the treatment of lateral recess stenosis?

Answer 32

–Non-operative –Nerve root injection –Epidural injection –Surgery

Question 33

What are the causes of lateral recess stenosis?

Answer 33

**A bulging or herniated disc** Degenerative disc disease An enlarged facet joint Facet syndrome A thickened spinal ligament A misaligned vertebra (**spondylolisthesis**) **A bone spur** Spinal inflammation (**osteoarthritis**)

Question 34

What are the clinical features of central stenosis?

Answer 34

Lower back pain, tingling or numbness may radiate to the hips, buttocks, legs and sometimes the toes Dull and aching pain concentrated in the lower back may come and go; this pain may become more persistent over time or with movement such as running, walking, standing or bending In severe cases, leg pain and weakness can cause difficulty balancing and walking

Question 35

What is the treatment for central stenosis?

Answer 35

–Non-operative –Epidural steroid injection –Surgery (80% improve)

Question 36

What is treatment for foraminal stenosis?

Answer 36

–Non-operative –Nerve root injection –Epidural injection –Surgery

Question 37

What is the treatment of spondylolisthesis?

Answer 37

•Symptoms –Often vary with type of spondylolisthesis –Treatment depends on symptoms * Conservative with lifestyle changes * Surgery for persistent pain +/- nerve root entrapment