Spinal Injury and Disease (Disc Herniation, Mechanical Back Pain, Sciatica, Cauda Equina, Cervical and Lumbar Sponylosis, Spondylolysis, Spondylolisthesis) Flashcards
(85 cards)
1
Q
What are the two main components of a healthy intervertebral disc?
A
- 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.
2
Q
What is spondylosis?
A
Degeneration of the spine - also known as spinal osteoarthritis in the less broad sense
3
Q
What are the degenerative consequences to spondylosis?
A
- 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
4
Q
What can cause nerve root irritation?
A
- Nerve root compression by osteophytes
- Central spinal stenosis
- Spondylysis
- Spondylolisthesis
5
Q
What happens in IV disc herniation?
A
Tearing of annulus fibrosis and protrusion of the nucleus pulposus
6
Q
What are the different types of disc herniations?
A
- Bulge - generalised
- Protrusion - annulus weakened but still intact
- Herniation - through annulus but in continuity
- Sequestration - dessicated disc material free in canal
7
Q
What are the most common locations in the cervical vertebrae for IV disc herniations to occur?
A
C5/C6
8
Q
What are the most common locations in the thoracic spine for IV disc herniation to occur?
A
T11/T12
9
Q
What are the most common locations in the lumbar spine for IV disc hernation to occur?
A
By order of most common
- L4/5
- L5/S1
- L3/4
10
Q
Where would sensory loss occur in an L5/S1 disc herniation?
A
S1 dermatome - Little toe and sole of foot
11
Q
What nerve root is affected in an L5/S1 disc herniation?
A
S1 nerve root
12
Q
What motor deficit would be seen in an L5/S1 disc herniation?
A
Plantar flexion of the foot - gastrocnemius, flexor hallucis longus, abductor digiti minimi
13
Q
Which reflex would be affected in an L5/S1 disc herniation?
A
Ankle Jerk - S1/2 “buckle my shoe”
14
Q
Which nerve root would be affected in an L4/5 disc herniation?
A
L5 Nerve Root
15
Q
Where would sensory loss occur in an L4/5 disc herniation?
A
Great toe + 1st dorsal web space
16
Q
What motor deficit would be experienced in an L4/5 disc herniation?
A
Dorsiflexion of ankle and toes - especially EHL
17
Q
Which nerve root would be affected in an L3/4 disc hernation?
A
L4 nerve root
18
Q
What motor deficit would be experienced in a L3/4 disc herniation?
A
Quadriceps weakness
19
Q
What sensory deficit would occur in an L3/4 disc herniation?
A
Medial aspect of the lower leg
20
Q
What reflex could be affected in a L3/4 disc herniation?
A
Knee jerk - L3/4 - “kick in the door”
21
Q
What reflex could be affected in a L4/5 disc herniation?
A
NONE - both knee and ankle jerk remain normal as L5 nerve root supplies neither reflex
22
Q
How does a prolapsed IV disc commonly present?
A
-
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
23
Q
L3 Nerve root compression features
A
- Sensory loss over anterior thigh
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
24
Q
L4 Nerve root compression features
A
- Sensory loss anterior aspect of knee
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
25
L5 Nerve root compression features
* **Sensory loss dorsum of foot**
* **Weakness in foot and big toe dorsiflexion**
* **Reflexes intact**
* **Positive sciatic nerve stretch test**
26
S1 Nerve root compression features
* **Sensory loss posterolateral aspect of leg and lateral aspect of foot**
* **Weakness in plantar flexion of foot**
* **Reduced ankle reflex**
* **Positive sciatic nerve stretch test**
27
In IV disc herniation, how is acute back pain produced?
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.
28
What could occur if a lumbar IV disc herniated centrally rather than posterolaterally?
Cauda Equina syndrome
29
What is mechanical back pain?
Back pain which is worse with movement and relieved with rest
Arises from any aspect of the motion segment (bones, joints, ligmanents, discs)
30
What percentage of those with mechanical back pain recover within 6 weeks?
90%
31
What advice would you give to someone with mechanical back pain?
* ***_AVOID BED REST_*** - keep active
* **Simple analgesia**
* **Workplace/activity assessement?** - avoid twisting/lifting
* **Smoking cessation** - interferes with disc nutrition
32
How would you manage someone with back pain plus signs of nerve root pain?
Most settle on their own (90% within 3 months)
* **Physio**
* **Strong analgesia**
* **Referral after 12 weeks** - MRI
33
In someone with low back pain, what are the red flag symptoms/signs that would raise suspicion over the severity of the cause?
* **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**
* **Night pain**
34
In someone with low back pain, what risk factors could raise suspicion of more serious pathology?
Back pain, plus:
* **Previous malignancy**
* **Systemic illness**
* **Steroid use**
* **HIV**
* **IVDU**
* **Thoracic pain** - degenerative/metastatic change
35
What is sciatica?
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
36
What test can be done to screen for sciatica?
Streight leg raise - produces pain around 40o
37
What is cauda equina syndrome?
Syndrome that occurs due to compression of the cauda equina
38
What can cause cauda equina syndrome?
* **Tumour**
* **LD prolapse**
* **Spinal stenosis**
* **Traumatic injury**
* **Epidural Abscess**
* **Spinal surgery**
* **Spinal Manipulation**
* **Spinal epidural infection**
39
What are the clinical features of cauda equina syndrome?
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
40
If there was damage of S2-S5, what motor deficit would there be?
Sphincter deficit
41
If there was damage at the level of S2-S5, what sensory deficit would be present?
Perianal and saddle (perineum, external genitalia)
42
If there was damage at the S2-S5 level, what reflex would be affected?
Bulbocavernous reflex
43
If you suspect someone has cauda equina syndrome, how should you investigate?
**Clinical Diagnosis, followed by emergency imaging** - MRI
44
If you have confirmed someone has cauda equina, what is the next step to take in their management?
**IMMEDIATE SURGICAL DECOMPRESSION -** Within 48h
45
What is the pathogenesis of spondylosis?
* 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
**Cervical spondylosis is an extremely common condition that results from osteoarthritis.
It most commonly presents as neck pain although referred pain may mimic headaches etc.
Complications include radiculopathy and myelopathy.**
46
What is cervical spondylotic radiculopathy (CSR)?
**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
47
What is cervical spondylotic myelopathy (CSM)?
**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
48
What causes cervical spondylosis?
* **Spontaneous joint degeneration** - acquired with age (\>40)
* **Trauma**
* **Surgery** - Cervical
49
How does cervical spondylosis present?
* **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
50
If someone with cervical spondylosis showed siminished relfexes in the arm, would they have cervical radiculopathy or myelopathy?
Cervical Radiculopathy
51
If someone with suspected cervical spondylosis presents iwth increased relexes in the arm, would you suspect cervical radiculopathy or myelopathy?
**Cervical myelopathy** - damages descending pathways which inhibit reflex arc
52
What is the peak age of onset of cervical spondylosis in males and females?
* Male \>60
* Female \>50
53
How would you investigate suspected cervical spondylosis?
* **Imaging**
* Cervical MRI
* Cervical X-Ray
54
How would you manage someone with cervical spondylosis?
**General**
* Physiotherapy
* Traction therapy
**Specific**
* NSAIDS
* Muscle relaxants
* Trigger point/facet joint injection
**Surgery** - IF CSR/CSM - Decompression
55
How does lumbar spondylosis present?
* **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**
56
How would you investigate lumbar spondylosis?
**Imaging**
* Plain x-ray
* MRI
* CT myelography
* CT spine
**Other**
* EMG walking test
57
Where in the spine can lumbar spondylosis occur?
* **Central** – spinal claudication
* **Lateral recess** – symptoms in distribution of nerve root
* **Foraminal** – pressure on nerve root – individual nerve root distribution
58
How would you treat someone with lumbar spondylosis?
**General**
* Activity modification +/- Use of physical aids
* Physiotherapy
* Spinal manipulation/Massage
**Pharmacological -** NSAIDS, Paracetamol, Nerve root injection, Epidural steriod injection
**Surgery**
59
What is spondylolysis?
Defect/stress fracture of pars interarticularis - part between the superior and inferior facets
60
What is spondylolysis caused by?
**Trauma** - Stress fracture of vertebrae
Pars interarticularis vulnerable to fracture during hyperextension combined with rotation
61
How does someone with spondylolysis present?
* **Pain +/- radicular signs** - worsened by hyperextension
* **Positive Stork test**
* **Excessive lordotic posture**
* **Unilateral tenderness**
62
How would you investigate spondylolysis?
**Imaging -** X-Ray, CT, MRI, Bone scan
63
What is spondylolisthesis?
Displacement of one lumbar vertebrae on the vertebrae below
64
Which direction does spondylolisthesis usually occur?
Forward
65
Where does spondylolisthesis most commonly occur?
L5/S1
66
What classification system is used to radiographically classify spondylolisthesis?
**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
67
What can cause spondylolisthesis?
* **Spondylosis** - degenerative spondylolisthesis
* **Trauma****tic**
* **Congenital malformation**
68
How does spondylolisthesis present?
* **Can be asympotomatic**
* **Pain** - dull ache +/- sharp sciatic pain
* **Tight hamstrings** ⇒ waddling gait
* **Positive straight leg raise**
69
How would you investigate spondylolisthesis?
**Imaging** - X-ray and MRI
70
How would you manage someone with sponylolisthesis?
* **Conservative** - bracing and physio - temporary relief
* **Surgery** - spinal fusion (essential for grade III-V)
71
How would you manage someone with spondylolysis?
* **Conservative** - e.g rest + bracing
* **Injection therapy**
* **Surgery**
72
What is lumbar spinal stenosis and lateral recess steonsis?
Generalised narrowing of the spinal canal or its lateral recesses causing serve ischaemia ⇒ SPINAL CLAUDICATION
Typically caused by facet joint OA or osteophytes
Releived by sitting down, leaning forwards and crouching down
73
What are red flag signs of mechanical back pain?
* **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**
74
If a patient had back pain which got worse throughout the day with early morning stiffness, what would be the most likely cause?
Mechanical back pain/OA
75
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?
Inflammatory back pain e.g. Ankylosing spondylitis
76
If someone had back pain which woke them at night/was present at night, what would be important to exclude?
* **Infection**
* **Malignancy**
77
Where would pain be experienced in L1 nerve root compression?
Inguinal region
78
Where would pain be present in L2/3/4 nerve root compression?
Back, radiating into anterior thigh, and at times medial lower leg
79
Where would L5 nerve root compression pain be felt?
Back, radiating into buttock, lateral thigh, lateral calf and dorsum of foot and great toe
80
Where would pain from an S! nerve root compression be felt?
Back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot
81
Whats discitis?
Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.
82
Features of discitis
* **Back pain**
* **General features: pyrexia, rigors, sepsis**
* **Neurological features if epidural abscess develops**
83
Causes of discitis
* **Bacterial: Staphylococcus aureus is the most common cause**
* **Viral**
* **TB**
* **Aseptic**
84
Diagnosis of discitis
* **Imaging: MRI has the highest sensitivity**
* **CT guided biopsy may be required to guide antimicrobial treatment**
85
Management of discitis
**Assess the patient for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere**
