Spinal Injury and Disease (Disc Herniation, Mechanical Back Pain, Sciatica, Cauda Equina, Cervical and Lumbar Sponylosis, Spondylolysis, Spondylolisthesis)

Question 1

What are the two main components of a healthy intervertebral disc?

Answer 1

• Nucleus pulposus - distortable, incompressible semi-fluid gel. Mainly water (88%) + collagen and proteoglycans (very hydrophilic)
• Annulus Fibrosus - surrounds nucleus pulposus. Provides resistance to multi-directional forces and accounts for the stability of the disc.

Question 2

What is spondylosis?

Answer 2

Degeneration of the spine - also known as spinal osteoarthritis in the less broad sense

Question 3

What are the degenerative consequences to spondylosis?

Answer 3

• Formation of circumferential or radial tears within the annulus fibrosus
• Sensitisation of the pain nociceptors that are located inside the annulus
• Loss of disc height and facet joint arthrosis
• Disc herniation and nerve root irritation - usually posterolateral
• Hypertrophic changes resulting in spinal stenosis

Question 4

What can cause nerve root irritation?

Answer 4

• Nerve root compression by osteophytes
• Central spinal stenosis
• Spondylysis
• Spondylolisthesis

Question 5

What happens in IV disc herniation?

Answer 5

Tearing of annulus fibrosis and protrusion of the nucleus pulposus

Question 6

What are the different types of disc herniations?

Answer 6

• Bulge - generalised
• Protrusion - annulus weakened but still intact
• Herniation - through annulus but in continuity
• Sequestration - dessicated disc material free in canal

Question 7

What are the most common locations in the cervical vertebrae for IV disc herniations to occur?

Answer 7

C5/C6

Question 8

What are the most common locations in the thoracic spine for IV disc herniation to occur?

Answer 8

T11/T12

Question 9

What are the most common locations in the lumbar spine for IV disc hernation to occur?

Answer 9

By order of most common

1. L4/5
2. L5/S1
3. L3/4

Question 10

Where would sensory loss occur in an L5/S1 disc herniation?

Answer 10

S1 dermatome - Little toe and sole of foot

Question 11

What nerve root is affected in an L5/S1 disc herniation?

Answer 11

S1 nerve root

Question 12

What motor deficit would be seen in an L5/S1 disc herniation?

Answer 12

Plantar flexion of the foot - gastrocnemius, flexor hallucis longus, abductor digiti minimi

Question 13

Which reflex would be affected in an L5/S1 disc herniation?

Answer 13

Ankle Jerk - S1/2 “buckle my shoe”

Question 14

Which nerve root would be affected in an L4/5 disc herniation?

Answer 14

L5 Nerve Root

Question 15

Where would sensory loss occur in an L4/5 disc herniation?

Answer 15

Great toe + 1st dorsal web space

Question 16

What motor deficit would be experienced in an L4/5 disc herniation?

Answer 16

Dorsiflexion of ankle and toes - especially EHL

Question 17

Which nerve root would be affected in an L3/4 disc hernation?

Answer 17

L4 nerve root

Question 18

What motor deficit would be experienced in a L3/4 disc herniation?

Answer 18

Quadriceps weakness

Question 19

What sensory deficit would occur in an L3/4 disc herniation?

Answer 19

Medial aspect of the lower leg

Question 20

What reflex could be affected in a L3/4 disc herniation?

Answer 20

Knee jerk - L3/4 - “kick in the door”

Question 21

What reflex could be affected in a L4/5 disc herniation?

Answer 21

NONE - both knee and ankle jerk remain normal as L5 nerve root supplies neither reflex

Question 22

How does a prolapsed IV disc commonly present?

Answer 22

• Severe pain
  
  • Worse on coughing, laughing, sneezing, twisting
  • Can be confined to lower lumbar area (lumbago) or radiate down buttocks or leg (sciatica)
• Limited forward flexion and extension +/- lateral rotation
• Nerve root specific signs - motor/sensory/reflex deficit
• Positive Straight Leg Raise - Sciatica

Question 23

In IV disc herniation, how is acute back pain produced?

Answer 23

Pressure of the nucleus upon the posterior longitudinal ligament and dura mater produces acute back pain.

Later, the herniation deviates laterally to impinge upon the traversing nerve root.

Question 24

What could occur if a lumbar IV disc herniated centrally rather than posterolaterally?

Answer 24

Cauda Equina syndrome

Question 25

What is mechanical back pain?

Answer 25

Back pain which is worse with movement and relieved with rest Arises from any aspect of the motion segment (bones, joints, ligmanents, discs)

Question 26

What percentage of those with mechanical back pain recover within 6 weeks?

Answer 26

90%

Question 27

What advice would you give to someone with mechanical back pain?

Answer 27

* ***_AVOID BED REST_*** - keep active * **Simple analgesia** * **Workplace/activity assessement?** - avoid twisting/lifting * **Smoking cessation** - interferes with disc nutrition

Question 28

How would you manage someone with back pain plus signs of nerve root pain?

Answer 28

Most settle on their own (90% within 3 months) * **Physio** * **Strong analgesia** * **Referral after 12 weeks** - MRI

Question 29

In someone with low back pain, what are the red flag symptoms/signs that would raise suspicion over the severity of the cause?

Answer 29

* **Traumatic injury** * **Urinary/faecal incontinence** * **Saddle anaesthesia** * **Progressive leg weakness/non-mechanical back pain** * **Severe abdo/low back pain** * **Gait disturbance** * **Weight loss** * **Neurological signs**

Question 30

In someone with low back pain, what risk factors could raise suspicion of more serious pathology?

Answer 30

Back pain, plus: * **Previous malignancy** * **Systemic illness** * **Steroid use** * **HIV** * **IVDU** * **Thoracic pain** - degenerative/metastatic change

Question 31

What is sciatica?

Answer 31

Pain which radiates from the back into the buttock, thigh, calf and occasionally the foot. Numbness and paraesthesia occurs in same distribution Onset can be sudden or gradual

Question 32

What test can be done to screen for sciatica?

Answer 32

Streight leg raise - produces pain around 40^o

Question 33

What is cauda equina syndrome?

Answer 33

Syndrome that occurs due to compression of the cauda equina

Question 34

What can cause cauda equina syndrome?

Answer 34

* **Tumour** * **LD prolapse** * **Spinal stenosis** * **Traumatic injury** * **Epidural Abscess** * **Spinal surgery** * **Spinal Manipulation** * **Spinal epidural infection**

Question 35

What are the clinical features of cauda equina syndrome?

Answer 35

LMN lesion * **Back pain** * **Sensory loss in root distribution** * **Saddle anaesthaesia** * **Loss of anal tone and anal reflex** * **Urinary retention with overflow incontinence** * **Leg weakness** - Asymmetrical, atrophic, areflexive paralysis

Question 36

If there was damage of S2-S5, what motor deficit would there be?

Answer 36

Sphincter deficit

Question 37

If there was damage at the level of S2-S5, what sensory deficit would be present?

Answer 37

Perianal and saddle (perineum, external genitalia)

Question 38

If there was damage at the S2-S5 level, what reflex would be affected?

Answer 38

Bulbocavernous reflex

Question 39

If you suspect someone has cauda equina syndrome, how should you investigate?

Answer 39

**Clinical Diagnosis, followed by emergency imaging** - MRI

Question 40

If you have confirmed someone has cauda equina, what is the next step to take in their management?

Answer 40

**IMMEDIATE SURGICAL DECOMPRESSION -** Within 48h

Question 41

What is the pathogenesis of spondylosis?

Answer 41

* Disc joints become dehydrated and narrow ⇒ Facet joint degeneration due to increased axial loading * Annulus can become innervated and develop osteophytes at margins * Radiculopathy and central stenosis can develop

Question 42

What is cervical spondylotic radiculopathy (CSR)?

Answer 42

**CAUSES LMN LESION** Nerve exiting the spinal cord/canal is pinched by either disc degeneration alone (i.e., herniated disc) or with moderate to severe degenerative changes, narrowing the root exit at the foraminal level

Question 43

What is cervical spondylotic myelopathy (CSM)?

Answer 43

**CAUSES UMN LESION** Severe disc and facet degeneration with changes in spine alignment, such as kyphosis or spondylolisthesis, along with osteophyte formation Lead to a significantly narrowed spinal canal and secondary spinal cord deformation

Question 44

What causes cervical spondylosis?

Answer 44

* **Spontaneous joint degeneration** - acquired with age (\>40) * **Trauma** * **Surgery** - Cervical

Question 45

How does cervical spondylosis present?

Answer 45

* **Usually asymptomatic** * **Neck Pain +/- muscle spasm** * **Decreased ROM** * **Signs of nerve/spinal cord compression** * **Level of lesion -** LMN Radiculopathy - Arm pain +/- paraesthesiae, flaccid weakness * **Below level of lesion -** UMN myelopathy - Spastic weakness etc

Question 46

If someone with cervical spondylosis showed siminished relfexes in the arm, would they have cervical radiculopathy or myelopathy?

Answer 46

Cervical Radiculopathy

Question 47

If someone with suspected cervical spondylosis presents iwth increased relexes in the arm, would you suspect cervical radiculopathy or myelopathy?

Answer 47

**Cervical myelopathy** - damages descending pathways which inhibit reflex arc

Question 48

What is the peak age of onset of cervical spondylosis in males and females?

Answer 48

* Male \>60 * Female \>50

Question 49

How would you investigate suspected cervical spondylosis?

Answer 49

* **Imaging** * Cervical MRI * Cervical X-Ray

Question 50

How would you manage someone with cervical spondylosis?

Answer 50

**General** * Physiotherapy * Traction therapy **Specific** * NSAIDS * Muscle relaxants * Trigger point/facet joint injection **Surgery** - IF CSR/CSM - Decompression

Question 51

How does lumbar spondylosis present?

Answer 51

* **Pain** - particularly on extension * **Neurogenic Claudication** - sensory dysaesthesia, weakness, relieved on flexion of spine (e.g. sitting down), worse on extension (e.g. going downhill) * **Stooped posture** * **Radiculopathic signs**

Question 52

How would you investigate lumbar spondylosis?

Answer 52

**Imaging** * Plain x-ray * MRI * CT myelography * CT spine **Other** * EMG walking test

Question 53

Where in the spine can lumbar spondylosis occur?

Answer 53

* **Central** – spinal claudication * **Lateral recess** – symptoms in distribution of nerve root * **Foraminal** – pressure on nerve root – individual nerve root distribution

Question 54

How would you treat someone with lumbar spondylosis?

Answer 54

**General** * Activity modification +/- Use of physical aids * Physiotherapy * Spinal manipulation/Massage **Pharmacological -** NSAIDS, Paracetamol, Nerve root injection, Epidural steriod injection **Surgery**

Question 55

What is spondylolysis?

Answer 55

Defect/stress fracture of pars interarticularis - part between the superior and inferior facets

Question 56

What is spondylolysis caused by?

Answer 56

**Trauma** - Stress fracture of vertebrae Pars interarticularis vulnerable to fracture during hyperextension combined with rotation

Question 57

How does someone with spondylolysis present?

Answer 57

* **Pain +/- radicular signs** - worsened by hyperextension * **Positive Stork test** * **Excessive lordotic posture** * **Unilateral tenderness**

Question 58

How would you investigate spondylolysis?

Answer 58

**Imaging -** X-Ray, CT, MRI, Bone scan

Question 59

What is spondylolisthesis?

Answer 59

Displacement of one lumbar vertebrae on the vertebrae below

Question 60

Which direction does spondylolisthesis usually occur?

Answer 60

Forward

Question 61

Where does spondylolisthesis most commonly occur?

Answer 61

L5/S1

Question 62

What classification system is used to radiographically classify spondylolisthesis?

Answer 62

**Meyerding Classification** * **Grade 1** - 0 to 25% * **Grade 2** - 25 to 50% * **Grade 3** - 50 to 75% * **Grade 4** - 75 to 100% * **Spondyloptosis** - body of L5 vertebra sitting in front of S1

Question 63

What can cause spondylolisthesis?

Answer 63

* **Spondylosis** - degenerative spondylolisthesis * **Trauma****tic** * **Congenital malformation**

Question 64

How does spondylolisthesis present?

Answer 64

* **Can be asympotomatic** * **Pain** - dull ache +/- sharp sciatic pain * **Tight hamstrings** ⇒ waddling gait * **Positive straight leg raise**

Question 65

How would you investigate spondylolisthesis?

Answer 65

**Imaging** - X-ray and MRI

Question 66

How would you manage someone with sponylolisthesis?

Answer 66

* **Conservative** - bracing and physio - temporary relief * **Surgery** - spinal fusion (essential for grade III-V)

Question 67

How would you manage someone with spondylolysis?

Answer 67

* **Conservative** - e.g rest + bracing * **Injection therapy** * **Surgery**

Question 68

What is lumbar spinal stenosis and lateral recess steonsis?

Answer 68

Generalised narrowing of the spinal canal or its lateral recesses causing serve ischaemia ⇒ SPINAL CLAUDICATION Typically caused by facet joint OA or osteophytes

Question 69

What are red flag signs of mechanical back pain?

Answer 69

* **Past Hx of Ca, steroids, HIV** * **First acute onset \<20/\>50** * **Non mechanical pain** * **Thoracic pain** * **Weight loss** * **Systemically unwell** * **Widespread neurology** * **Structural deformity/trauma**

Question 70

If a patient had back pain which got worse throughout the day with early morning stiffness, what would be the most likely cause?

Answer 70

Mechanical back pain/OA

Question 71

If a patient had back pain which was worst in the morning and got better on exertion/throughout the day, what would be the most likely cause be?

Answer 71

Inflammatory back pain e.g. Ankylosing spondylitis

Question 72

If someone had back pain which woke them at night/was present at night, what would be important to exclude?

Answer 72

* **Infection** * **Malignancy**

Question 73

Where would pain be experienced in L1 nerve root compression?

Answer 73

Inguinal region

Question 74

Where would pain be present in L2/3/4 nerve root compression?

Answer 74

Back, radiating into anterior thigh, and at times medial lower leg

Question 75

Where would L5 nerve root compression pain be felt?

Answer 75

Back, radiating into buttock, lateral thigh, lateral calf and dorsum of foot and great toe

Question 76

Where would pain from an S! nerve root compression be felt?

Answer 76

Back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot