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

Question 1

what is the most common form of disc prolapses?

Answer 1

Normal spinal cord finishes at a level of above L1 and below that we just have spinal roots

Most common form of disc prolapses is lateral but occasionally central can be seen which causes different symptoms

Question 2

what type of joint are Intervertebral Discs?

Answer 2

Secondary Cartilaginous Joint

Question 3

what is the structure of the intervertebral discs?

Answer 3

• Disc is largest avascular structure in the body
• Annulus fibrosus - Tough outer layer
• Nucleus pulposus - Gelatinous core
• Annulus may tear and nucleus prolapse - Can cause cord/nerve root compression

Question 4

• Cartilaginous end plate of each disc attaches to bony endplate of ________
• The ___ and ___ connect discs with vertebral bodies
• The fibres of the annulus fibrosis (collagen) run ________ and alternately between layers
• They resist ________ movements
• Discs fail with _______ movements

Answer 4

vertebra

ALL and PLL

obliquely

rotational

twisting

Question 5

what make sup the inververtebral disc?

Answer 5

• The nucleus pulposus consists mainly of water - 88%
• • collagen & proteoglycans (very hydrophilic)
• The disc is kidney bean shaped

Question 6

Disc prolapses are usually __________

Answer 6

postero-lateral

Question 7

what happens to the intervertebral discs as part of the normal ageing process?

Answer 7

• Decreased water content of discs (see this on MRI)
• Disc space narrowing
• “Degenerative” changes on X-rays
• Degenerative changes in the facet joints
• Aggravated by smoking, etc.

Question 8

what are some different Pathological Processes?

Answer 8

• Tearing of annulus fibrosis and protrusion of the nucleus
• Nerve root compression by osteophytes
• Central spinal stenosis
• Abnormal movement (between vertebra)
• Spondylolysis
• Spondylolisthesis

Question 9

what is nerve root pain like?

Answer 9

• Fairly common
• Limb pain worse than back pain
• Pain in a nerve root distribution (radicular)
• Root tension signs (sciatic nerve stretch test)
• Root compression signs
• Dermatomes & myotomes

Question 10

what does radicular mean?

Answer 10

Pain in a nerve root distribution

Question 11

what is the management of nerve root pain?

Answer 11

• Most will settle, about 90% in 3 months (without surgical intervention)
• Physiotherapy
• Strong analgesia
• Referral after 12 weeks
• Imaging - MRI (this is the modality of choice)

Question 12

MRI Scans showing disc prolapse in the second one and first is normal

Spinal canal boundaries:

Anterior – vertebral body

Posterior – laminar and facet joints posteriorly

Answer 12

Question 13

whata re the different kinds of disc problems?

Answer 13

• Bulge (generalised) – common, majority asymptomatic, relevance?, nucleus contained, annulus slightly buldging
• Protrusion (annulus weakened but still intact)
• Extrusion (through annulus but in continuity)
• Sequestration (dessicated disc material free in canal)

Question 14

what regions do disc prolapses most often occur?

Answer 14

Lumbar > cervical > thoracic

Question 15

wher eis a Cervical Disc Prolapse most common?

Answer 15

Most commonly C5/6

Question 16

how often and where do thoracic disc prolapses occur?

Answer 16

• <1% of intervertebral disc prolapses
• Mid to lower levels (75% T8-12)
• Most at T11/12
• Central, posterolateral and lateral herniations

Question 17

where do lumbar disc prolapses occur?

Answer 17

• Usually L4/5 (45%), followed by L5/S1 (40%), then L3/4 (10%)
• Most are posterolateral - (Posterior Longitudinal Lig weakest)

L3/4 – femoral neuralgia, pain on the anterior of the thigh

L5/S1 – symptoms are pain going right down the leg into the foot and

Question 18

what may central fisc prolapses in the lumbar region cause?

Answer 18

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

Question 19

Prolapsed Lumbar Inter-Vertebral Disc - summary table

Answer 19

EHL - extensor hallucis longus

Question 20

what is Cauda Equina Syndrome?

Answer 20

Compression of cauda equina

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

Question 21

what is the treatment of cauda equina syndrome?

Answer 21

Cant be treated conservatively

Need to treat rapidly

• Surgical emergency - admission, urgent MRI scan, emergency operation within 48h of onset; delay results in permanent dysfunction

Question 22

what is the aetiology of cauda equina syndrome?

Answer 22

central lumbar disc prolapse (commonest)

tumours

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

infection (epidural abscess – rare in this country)

iatrogenic (spinal surgery or manipulation, spinal epidural injection)

Question 23

whata re the clinica features of cauda equina syndrome?

Answer 23

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 24

in cauds erquina syndrome is there a Delay in diagnosis?

Answer 24

•Shapiro (USA) – average delay 9 days

–4 patient related

–20 physician related!!

•Surgical emergency

Question 25

in cauda equina syndrome what is used for radiographic evaluation?

Answer 25

MRI If contraindicated, then lumbar CT myelogram Maybe if the patient has mental implants like pacemaker

Question 26

what is the treatment of cauda equina syndrome?

Answer 26

OPERATIVE! Within 48h (of onset of symptoms) (statistically significant improvement and difference if surgery \< 48 hrs)

Question 27

what is the outcome of cauds equina syndrome?

Answer 27

* 30% undergoing discectomy for cauda equina syndrome did NOT regain normal urinary function * 25% with motor deficits never regained full power (A motor deficit is a poor prognostic feature) * 33% with sensory deficits never regained normal sensation * 25% with perianal paraesthesiae did not return to normal * 26% had persitent sexual dysfunction

Question 28

what is Cervical and lumbar spondylosis (OA)?

Answer 28

Cervical spondylosis is also called cervical osteoarthritis. It is a condition involving changes to the bones, discs, and joints of the neck. These changes are caused by the normal wear-and-tear of aging. With age, the discs of the cervical spine gradually break down, lose fluid, and become stiffer * Common - Very common in cervical and lumbar areas of the spine * Degenerative change at - Facet joints, discs, ligaments, etc. * If severe, can compress whole cord (not just nerve roots) causing myelopathy - UMN signs in limbs (increased tone, brisk reflexes, etc.) Degenerative changes cause osteophytes to form and calcification of the ligaments and leaves narrow space for nerves In cervical spine the whole spinal cord can be compressed and cause a myelopathy In lumbar they often don’t have upper motor neuron signs

Question 29

Lumbar Spine - what is the role of the facet joints and the intervertebral discs?

Answer 29

* The facet joints (true synovial joints) allow mainly flexion and extension * The intervertebral discs (secondary cartilaginous joints) are specialised joints to allow movement between vertebrae

Question 30

whata re the ligaments of the spine?

Answer 30

* Anterior Longitudinal Ligament (ALL – along the front of the vertebral bodies – broad, strong) * Posterior Longitudinal Ligament (PLL – along the backs of the vertebral bodies, i.e. front of the spinal canal; narrower) * Ligamentum Flavum (between laminae) * Interspinous and Supraspinous Ligaments (between spinous processes) * Intertransverse Ligament (between transverse processes)

Question 31

what is Lumbar spondylosis?

Answer 31

•OA of facet and disc joints (+ degeneration of ligaments, etc.) Narrowing of disk space, osteophytes narrow the vertebral body, facet joints become arthritic so narrow, sclerotic and irregular

Question 32

what is spinal claudicaitona nd its presentation?

Answer 32

•Distinguish from vascular claudication - Usually bilateral - Sensory dysaesthesiae - Poss weakness (drop foot – tripping) - Takes several minutes to ease after stopping walking (unlike vascular) - Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle

Question 33

Normal Canal

Answer 33

Stenotic Canal

Question 34

what ar ethe different types of Spinal Stenosis?

Answer 34

* Lateral recess stenosis * Central stenosis (bilateral symptoms) * Foraminal stenosis

Question 35

what is hte treatment of Lateral Recess Stenosis?

Answer 35

Non-operative Nerve root injection Epidural injection (more general and doesn’t treat a specific area) Surgery

Question 36

what is important in Central Stenosis?

Answer 36

•Canal shape important (congenital) - esp. trefoil canal

Question 37

what is the treatment of central stenosis?

Answer 37

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

Question 38

what si the treament of Foraminal stenosis?

Answer 38

Non-operative Nerve root injection Epidural injection Surgery (70% of patients respond to surgery) When the nerve root is compressed just as it exits the spine Most settle in 3 months (90%)

Question 39

Spondylolisthesis and Spondylolysis

Answer 39

When one vertebra is translated on another Posterior elements are separated form the anterior elements

Question 40

what are the symptoms and treatment of Spondylolisthesis?

Answer 40

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