Flashcards in The Vertebral Column & The Spinal Cord Deck (19):
What is the overall structure and function of the vertebral column
(24 x discrete, 9 x fused)
(7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccyx)
Vertebral body covered by hyaline cartilage
Vertebrae separated by intervertebral discs
Consecutive vertebrae foramina form the central canal
What is the structure and function of the intervertebral discs?
Outer ring - annulus fibrosis - tough, collagenous fibrocartillage
Inner - nucleus pulposus - remnant of the notochord - jelly-like structure
Flexibility of the spine and shock absorption
What is the overall structure of the spinal cord?
Begins at the foramen magnum
Gives off spinal nerves through intervertebral foramina (dorsal afferents, ventral efferents - above the corresponding cervical vertebrae and below thoracic vertebrae to form C8)
Ends of the conus medullaris around L1/L2
Tapered to the sacrum by the filum terminale
Cauda equina formed by lumbar and sacral nerves branching off the end of the spinal cord
What are the red flag symptoms for back pain?
Presentation under the age of 20 or onset over 55
Past history of carcinoma, steroids, HIV, Immunosuppresion
Fever and weight loss
Widespread neurological symptoms or signs - ?cauda equina
What are the yellow flag symptoms in back pain?
Psychological factors associated with poor prognosis - screen these patients for depression
A negative attitude towards back pain
Reduced physical activity, fear avoidance
An expectation for passive treatment
Social or financial problems
What is meant by chronic back pain?
What are the risk factors?
Pain that persists for 12 weeks or longer, even after an initial injury or underlying causes of acute lower back pain has been treated.
High BMI, reduced exercise, smoking, heavy physical work, repetitive lifting
What are the management options for chronic back pain?
Strengthening exercises - stay as active as possible
Medications - pain ladder - regular simple pain relief
What is meant by the STarT screening tool?
Screening tool for lower back pain in the past two weeks
Covering physical and psychological symptoms, questionnaire
Low risk - self care
Medium risk - physiotherapy
High risk - physiotherapy plus - specialist back pain physiotherapy +/- CBT
What are the NICE guidelines on suspected cancer with a patient presenting with back pain?
In patients with back pain, weight loss and over the age of 60, consider pancreatic cancer - urgent CT
In patients with persistent back pain and over the age of 60, consider myeloma - FBC, ESR and calcium
What is the mechanism of lumbar disc herniation?
Recurrent torsional strain leads to tears of outer annulus with herniation of the nucleus pulposus. Often triggered by heavy lifting, straining etc
Most commonly L5/S1 > L4/L5
Only 5% become symptomatic
Most commonly posterolateral
What are the symptoms of lumbar disc herniation?
Lower back pain
Radicular pain (buttock and leg pain)
May have weakness, sensory deficit, loss of reflexes depending on site of nerve impingement
L5/S1 - straight leg raise is a provocative test
What is the management of lumbar disc herniation?
Non-op: 90% improve without surgery
1st line- rest, activity as tolerated, NSAIDs, PT
2nd line - selective nerve root corticosteroid injections
Op- laminotomy and discectomy
Indicated with persistent disability pain, progressive and significant weakness
What is meant by spinal stenosis?
Narrowing of the central canal leading to compression of the cord
Often experienced in the lumbar spine
The narrowing can be due to bony structures (e.g. Osteophytes, spondylolithesis) or soft tissue structures (e.g. Discs)
What is meant by neurogenic intermittent claudication?
Pain secondary to nerve impingement
Going down stairs is painful as the back is extended. Flexion/lea img forward relieves the pain. This posture increases the limited area available in the canal ad the foramina
Worse with prolonged standing
What are the appropriate investigations in neurogenic intermittent claudication?
How can it be managed?
AP and lateral X-Rays
Treatment of underlying problem i.e. Disc herniation
Conservative/Non-op NSAIDs, physio, CS
Op: decompression +/- fusion
What is meant by spondylolithesis?
How does it present?
Forward slipping of one vertebrae on another
(It can be caused by spondylolysis)
Back pain, may progress to nerve root impingement leading to sciatica. Hyperextension is painful
What is meant by spondylolysis?
What is the characteristic sign on oblique x-rays?
This is a defect in the pars interarticularis (instability of the facet joints) which may allow the vertebrae to slip (spondylolithesis)
Collar on Scottie dog
What are the risk factors for discitis/vertebral osteomyelitis?
What are the common causative micro-organisms?
IVDU, recent infection, immunosuppression, recent surgery to the disc
Staph and strep
Also consider TB