Session 2: Clinical Conditions Related to the Vertebral Column

Question 1

Give examples of clinical conditions related to the vertebral column.

Answer 1

Mechanical back pain Marginal osteophytosis Herniation of an intervertebral disc (slipped disc) Sciatica Cauda equina syndrome Spinal canal stenosis Neurogenic claudication (symptom rather than a diagnosis) Spondylolisthesis

Question 2

Mechanical back pain is very common. 50% of the UK population report a certain regional back pain for at least 24 hours in any one year. Which kind of back pain?

Answer 2

Lumbar back pain.

Question 3

What are the risk factors of mechanical back pain?

Answer 3

Obesity Poor posture Sedentary lifestyle Poorly-designed seating Incorrect manual handling

Question 4

Explain marginal osteophytosis.

Answer 4

As we age the nucleus pulposus will dehydrate and degenerate. This leads to decrease in the high of the discs, bulging of the discs and alteration of stress loads meaning more is put onto the facet joints. Osteophytes called syndesmophytes will therefore develop adjacent the end plates of the discs. This is known as marginal osteophytosis.

Question 5

What are further consequences of the increased stress on the facet joints?

Answer 5

Osteoarthritic changes.

Question 6

Why are osteoarthritic changes painful?

Answer 6

The facet joints are innervated by meningeal branch of the spinal nerves so arthritis in the facet joints will be perceived as painful as they are pinched. Also: As the discs decrease in height and osteophytes develop at the facet joints and vertebral bodies the intervertebral foramina will narrow. This can lead to compression of the spinal nerves and will then be perceived as radicular or nerve pain.

Question 7

What is herniation of an intervertebral disc?

Answer 7

In lay terms it is called a slipped disc. Its pain comes. from herniated disc material pressing on a spinal nerve.

Question 8

There are four stages of disc herniation. Outline them.

Answer 8

1. Disc degeneration: Usually due to ageing discs can dehydrate and bulge due to chemical changes 2. Prolapse: Nucleus pulposus starts to slightly impinge into the spinal canal. However it is still contained within the annulus fibrosus. 3. Extrusion: Nucleus pulposus breaks out of the annulus fibrosus but it is still in the disc space. 4. Sequestration: The nucleus pulposus separates from the main body of the disc and enters the spinal canal.

Question 9

Where is slipped disc most common? Why?

Answer 9

L4/L5 and L5/S1. Because of the mechanical loading at these joints.

Question 10

What is the most common type of slipped disc? Which other types are there?

Answer 10

Paracentral prolapse (most common) Far lateral (2%) Central (2%)

Question 11

Why is central herniation especially dangerous?

Answer 11

Because it carries a risk of causing cauda equina syndrome.

Question 12

What is the exiting nerve root? Which type of herniation is the exiting nerve root susceptible of damage to?

Answer 12

The nerve root that emerges at the same level as the intervertebral disc. Most at risk in a far lateral herniation.

Question 13

What is the traversing nerve root? Which type of herniation is the traversing nerve root susceptible of damage to?

Answer 13

The nerve root that emerges at the level below the intervertebral disc. Most at risk in a paracentral herniation.

Question 14

If there is a paracentral herniation of the L4/L5 intervertebral disc. Which nerve is at risk of getting compressed?

Answer 14

The L5 root. Always the one below.

Question 15

Explain Sciatica.

Answer 15

Pain caused by irritation or compression of one or more of the nerve roots that contribute to the sciatic nerve.

Question 16

Which are the sciatic nerve roots? (What is the root value of the sciatic nerve?)

Answer 16

L4, L5, S1, S2, S3. L4-S3.

Question 17

What are some common causes of Sciatica?

Answer 17

Marginal osteophytosis and slipped disc.

Question 18

What are symptoms of Sciatica?

Answer 18

Pain in back and buttock that radiates to the dermatome supplied by the affected nerve root(s).

Question 19

If the nerve compression also causes paraesthesia, will the paraesthesia pattern of radiation be the same as the pain radiation?

Answer 19

No. Paraesthesia will only be experienced in the affected dermatome rather than the full path from lumbar spine to dermatome.

Question 20

What is cauda equina syndrome?

Answer 20

When there is some type of compression or irritation of usually the entire cauda equina.

Question 21

What is the most common cause of cauda equina?

Answer 21

Prolapsed intervertebral disc (disc herniation). Central disc herniation.

Question 22

What are some red flag symptoms of cauda equina syndrome?

Answer 22

Bilateral sciatica Perianal numbness Painless retention of urine Urinary/faecal incontinence Erectile dysfunction

Question 23

Why is cauda equina so important to catch early on?

Answer 23

It should be treated within 48 hours of the onset of symptoms. If this is not done there can be serious life-changing complications.

Question 24

What complications can arise from late detected cauda equina syndrome?

Answer 24

Chronic neuropathic pain Impotence Faecal incontinence Self-catherisation to pass urine Loss of sensation or lower limb weakness.

Question 25

What is spinal canal stenosis?

Answer 25

Abnormal narrowing of the spinal canal that compresses either the spinal cord or the nerve roots.

Question 26

Spinal canal stenosis usually affect the elderly. What are the most common causes of spinal canal stenosis?

Answer 26

Disc bulging Facet joint osteoarthritis Ligamentum flavus hypertrophy Compression fractures of the vertebral bodies Spondylolisthesis Trauma

Question 27

What types of spinal canal stenoses are most common?

Answer 27

Lumbar stenosis followed by cervical stenosis.

Question 28

Give some symptoms of spinal canal stenosis.

Answer 28

Discomfort while standing Discomfort or pain in upper or lower limbs Bilateral symptoms (70%) Numbness at or below level of the stenosis Weakness at or below level of the stenosis Neurogenic claudication

Question 29

What is neurogenic claudication?

Answer 29

A symptom rather than diagnosis. Reports of pain and/or pins and needles in the legs on prolonged standing or walking. Radiation of pain in a sciatic manner.

Question 30

What symptoms does neurogenic claudication ensue?

Answer 30

Pains and/or pins and needles in the legs on prolonged standing and on walking. Radiating sciatic distribution. Cramping pain or weakness in legs and therefore a tendency to limp. Neurogenic = nerve origin Claudication = limp (Claudigo)

Question 31

What are some causes of neurogenic claudication?

Answer 31

Compression of the spinal nerves. Leads to venous engorgement of the nerve roots during exercise. This leads to reduced arterial inflow and transient arterial ischaemia. The ischaemia that affects the nerves can result in pain and/or paraesthesia.

Question 32

How is neurogenic claudication generally treated?

Answer 32

By rest or change in position and flexion by the spine.

Question 33

What is spondylolisthesis?

Answer 33

Anterior displacement of the vertebra above on the vertebra below.

Question 34

There are some types of spondylolisthesis. Which?

Answer 34

Congenital or dysplastic

Isthmic

Degenerative

Traumatic

Pathological

Iatrogenic

Question 35

Give some symptoms of spondylolisthesis.

Answer 35

Gross instability of the vertebral column

Most complain of discomfort ranging from occasional back pain to incapacitating mechanical pain.

Sciatica from nerve root compression

Neurogenic claudication.

Some remain asymptomatic.

Question 36

Where is lumbar puncture performed?

Answer 36

Between the spinous processes of the L3 and L4 or L5.

Where you can find the cauda equina.