Disc Prolapse and Neurological Signs Quiz

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Questions and Answers

What is a common characteristic of lower motor neuron (LMN) lesions?

Spastic weakness

Little atrophy

Hyperreflexia

Atrophy (correct)

Which of these signs is indicative of upper motor neuron (UMN) lesions?

Fasciculations

Flaccid paralysis

Little atrophy (correct)

Hypo/areflexia

What is the likely outcome if the L4/L5 disc is affected?

Impact on the L5 nerve root (correct)

Impact on the L2 nerve root

Impact on the S1 nerve root

Impact on the L3 nerve root

What is a common initial symptom reduction period for most disc prolapse cases?

3 weeks Signup and view all the answers

Which stage of disc herniation is characterized by the inner disc pushing further into the outer layer without breaking through?

Stage 2 prolapsed disc Signup and view all the answers

Which imaging technique may still show a bulging disc even after symptomatic resolution?

MRI Signup and view all the answers

Disc prolapse commonly occurs in which part of the spine?

Lower lumbar region Signup and view all the answers

In cases of thoracolumbar syndrome, which nerves are implicated in referred pain to the buttocks and hip?

Cluneal nerves from T11-L5 Signup and view all the answers

What characterizes the progression from disc degeneration to a prolapsed disc?

Annular fibres weaken without nucleus protrusion Signup and view all the answers

What is a recommended position to alleviate pain in disc prolapse patients?

Antalgic positions Signup and view all the answers

Which neurological sign is most likely associated with upper motor neuron lesions?

Clonus Signup and view all the answers

What is the typical time frame for resorption and symptomatic resolution in disc prolapse?

6-8 weeks Signup and view all the answers

What is the typical location where lumbar nerve roots exit the spine?

Below the vertebral pedicle Signup and view all the answers

Which condition is characterized by irritation of the cluneal nerves?

Maigne’s syndrome Signup and view all the answers

Which symptom is NOT commonly associated with lateral spinal stenosis?

Bilateral weakness Signup and view all the answers

What is a hallmark test result expected in a patient with spinal stenosis?

Decreased reflexes Signup and view all the answers

What is a contraindicated treatment for disc prolapse?

Rotatory adjustments at the affected level Signup and view all the answers

Which of the following conditions is a risk factor for developing spinal stenosis at an earlier age?

Engaging in contact sports Signup and view all the answers

Which factor may predispose an individual to facet and capsular irritation in thoracolumbar syndrome?

Orientation of the facets changing Signup and view all the answers

What type of symptoms are typically seen with central spinal stenosis?

Bilateral symptoms Signup and view all the answers

Which condition can result from severe lumbar stenosis?

Cauda equina syndrome Signup and view all the answers

What are common aggravating factors for symptoms of lateral spinal stenosis?

Extension and ipsilateral lateral flexion Signup and view all the answers

What is the primary mechanism leading to spinal stenosis as a result of osteoarthritis?

Formation of synovial cysts Signup and view all the answers

What type of weakness is commonly associated with lateral spinal stenosis?

Flaccid weakness Signup and view all the answers

Study Notes

Pre-Learning Spinal Nerve Root Lesions

Spinal nerve roots travel downward via the dural sac or thecal sac
They need to travel vertically to the spinal level
Spinal nerve exits the IVF below the vertebral pedicle
L4/L5 disc most commonly impacted by disc prolapse
Occasionally L4 is affected, but more severe herniation
Disc prolapse is a tear in the annular fibres allowing the nucleus pulposus to push outwards
Typically tends to the posterior-lateral aspect of the discs
Cervical spine - lower cervical most common
Thoracic spine rarely affected due to stabilisation of rib cage
May see from trauma or conditions that predispose uneven weight transfer

Corticospinal Tract

Composed of upper motor neurons (UMN) and lower motor neurons (LMN)
UMN is motor cortex to the spinal level (synapse)
LMN is at the spinal level (synapse) to the muscle fibre (synapse) to muscle fibre

LMN and UMN Signs

LMN Signs:
- Flaccid weakness or paralysis
- Atrophy
- Fasciculations
- Hypo/areflexia
UMN Signs:
- Spastic weakness or paralysis
- Little atrophy (disuse over time)
- Hyperreflexia or clonus

Disc Prolapse Classification

Four stages of disc herniation: degeneration, prolapse, extrusion, sequestration
AKA bulge, slipped disc, prolapse
Stage 1 - Disc Degeneration
- Due to chemical changes, years of physical labour or acute or chronic stress
- Flexion/rotation injury often
- Annular fibres weaken, but nucleus remains encased
- May be present if had previous prolapse but elasticity in fibres not able to allow for full resorption
Stage 2 - Prolapsed Disc
- The inner disc pushes further into the outer layer of the disc
- Gives a prolapsed appearance
- Considered a bulging disc
- The inner nuclear material has still not broken through the fibrous wall
- 2 clinical outcomes:
  - Bulge may lead to chemical irritation of nearby nerves without actual compression
  - The bulge may compress nearby nerves or other spinal structures
Stage 3 - Extrusion
- The gel-like nucleus eventually breaks through the outer wall
- Even though it breaks through, the nucleus remains within the disc
- May have more severe symptoms due to greater damage
- Confirmation of MRI finding used to be a clinical indication of surgical requirements in the past
- Recent evidence extrusion has greatest tendency to decrease in size with conservative management
Stage 4 - Sequestration
- The nucleus breaks through the outer wall and eventually spills out of the spinal disc into the spinal canal
- The chemical components of the nucleus material can cause nerve inflammation, irritation, or pain to the effected nerve root
- Nerve roots above/below
- Cauda equina (if in lumbar spine)

Disc Prolapse - Location Classification

Classified by axial (from underneath) view on MRI
Disc = clock
- 6 o'clock = central disc herniation
- 5 or 7 o'clock = paracentral disc herniation (AKA posterolateral disc herniation)
- 4 or 8 o'clock = foraminal disc herniation
Located lateral to formina = far lateral disc herniation
Central and paracentral most common
Forminal and far lateral less common but more severe
Conservative care not as beneficial

Disc Prolapse

Typically an acute disc event occurring from age 25 to 50
Younger discs stronger unless put into early heavy challenge or trauma
Older discs desiccate and so are more stable
- Disc bulge possible but is due to loss of elasticity in annular fibres
Often not symptomatic
Is a long-term flexion/rotation type injury over months-years
Often have an "inciting event" that triggers pain (e.g., lifting)
Event can be non-traumatic (Valsalva type manoeuvre, rotation)

Disc Prolapse - Hallmark Characteristics

Burning/electrical LEG or ARM pain
Two main pain mechanisms for lower extremity pain
- Inflammatory mediators irritating nerve root (prostaglandins, leukotrienes, nitric oxide...)
- Mechanical pressure onto the nerve root

Disc Prolapse - Symptoms

Neurogenic pain or paraesthesia in a dermatome consistent and severe (7-8) for 3 weeks
Pain aggravated by flexion, IL lateral flexion, IL rotation
Pain may be reduced with CL lateral flexion – will not totally relieve
Valsalva type manoeuvres increase pain (cough, strain, sneeze)
Back pain due to annular tear and muscle spasm
DO NOT remove spasm – it's a protective mechanism - avoid further damage

Disc Prolapse - Other Symptoms

Myotomal weakness – flaccid type
Reduced reflex
May have exaggerated reflex below level of bulge
If severe and affecting nerve roots below it (lumbar spine more common) - Observe antalgic gait

Disc Herniation Imaging

MRI 2-3 months via NHS
- Many disc herniations likely resorbed
Private MRI fast but expensive
If minor - won't change your treatment plan
30% of population =asymptomatic disc herniation
"label" onto patient affecting behaviour
The longer a nerve is compressed, the more likely permanent damage is to occur
Conservative Rx not appropriate

Disc Prolapse - Refer If...

Significant functional weakness (3 or below)
Progressive neurological deficit
- More than 1 nerve root impacted
Unusually severe pain (7-8 normal)
Recovery not meeting timeframes
Signs of cauda equina
If occurred due to trauma (e.g. MVC) and fracture suspected

Natural History

Most disc prolapse will fully resorb on their own
Typically should have symptomatic reduction around 3 weeks
Typically should have resorption and symptomatic resolution 6-8 weeks
Some patients experience symptomatic resolution but "bulging disc" may remain visible on an MRI
Loss of elasticity of annular fibres although the disc is healed
No surgery typically required
Some patients continue to have residual symptoms from bulge remaining as above or nerve not gliding well in its sheath
If due to annular fibres losing elasticity, may need surgery to remove

Disc Prolapse - Treatment

Treatment may help to reduce symptomatic period
Improving blood flow
Improving biomechanics around the effected level
Advice to avoid exacerbation of inflammatory cycle
- Avoid things that make the pain go towards the extremity (e.g., flexion)
Positions that alleviate the pain or make it disappear from extremities are recommended (antalgic)
Rotatory adjustments at the level CONTRAINDICATED

Thoracolumbar Syndrome

AKA Maigne's syndrome
Maigne's syndrome actually a blanket diagnosis also looking at facet irritation (facet irritation of the lower portion of the thoracic spine and/or the upper lumbar spine)
Definition: Irritation of the cluneal nerves leading to referred pain in the buttocks and hip
Cluneal nerves – purely sensory branches of upper lumbar and lower thoracic nerves (T11 - L5 implicated)
Superior cluneal nerves most commonly implicated
Pathophysiology – not clearly understood
- Maigne's syndrome:
  - TL junction is less stable, bottom 2 ribs are not attached
  - Facet orientation changes in this region from a frontal plane in the thoracic to a sagittal plane in the lumbar
  - May predispose area to overload leading to facet and capsular irritation which irritate SCN
- Cluneal nerve entrapment:
  - SCN has to pass through the psoas major, lumbar paraspinals, and QL
  - Then passes through the TL fascia
  - Hypertonic muscles and thickening of fascial may lead to neural tension or compression
Who gets it?
- Very little known - highly underdiagnosed condition
- Instability – trauma or hypermobility may predispose
- Hypomobility of the TL junction
Women 64+ may be common population group
Symptoms:
- Pain will be aggravated by prolonged walking, extension, and rotation of the spine
- If other aspects of nerve irritated, may see flexion/squatting/sitting – less common
- Pain characterized typically as deep and aching
Referral pattern and visual representation of cluneal nerves
- Posterior pelvis (1), lateral thigh (2), and inguinal region (3)
Treatment:
- Case studies – suggest that conservative care may help
  - Manipulation of TL - hypomobility
  - Strengthening/stabilisation of TL - instability
  - Graston and myofascial release (muscles/fascia)
  - Stretching of muscles
  - Cluneal nerve flossing (modified sciatic floss)
- Medically - facet injection provides short-term relief
- Radio frequency ablation may provide longer-term results

Spinal Stenosis

Stenosis = narrow
Can be anything from a cyst, tumour, syrinx
Most commonly degenerative changes to the spine (in class – this is the type we are discussing!)
Three major types:
- Central: Compresses the central cord (discussed in the spinal cord lecture)
- Lateral: Compression as it exits the spinal canal
- Foraminal: Compression around the intervertebral foramen
  - Foraminal and lateral look exactly the same clinically – unilateral presentation on a nerve root
Pathophysiology
- Osteoarthritis
  - Formation of synovial cysts
  - Hypertrophy of the facet joints
  - Bone spur formation (osteophyte) enclosing IVF
Effect (Lateral Spinal Stenosis):
- 65+ unless have risk factors for earlier degeneration
- Trauma, contact sports, smoking...
- May report insidious, intermittent diffuse, crampy pain with paraesthesia
- If outright nerve compression: Burning or electrical pain
- Flaccid weakness, atrophy, a/hyporeflexia
- Would be relieved by opening manoeuvres (flexion, contralateral lateral flexion)
- Aggravated by closing manoeuvres (extension, ipsilateral lateral flexion)

Condition Revision (Flashcard!)

On your flashcard, put in:
- What is it – basic definition: This refers to a fundamental understanding of the medical condition in question, including its pathophysiology, etiology, and clinical presentation. It involves defining the disease, its progression, and how it varies from other similar conditions, providing an essential foundation for diagnosis and treatment.
- Who gets it – main population or risk factors: Identifying the demographic groups that are most susceptible to the condition. This includes age, gender, genetic predispositions, environmental exposures, lifestyle choices, and existing health conditions that may contribute to the increased risk of developing the disease.
- Hallmark symptoms – things that HAVE to be there: These are the key clinical manifestations that are essential for diagnosing the condition. Recognizing these symptoms is crucial, as their presence can help distinguish the disease from other similar conditions, guiding healthcare professionals in their assessments.
- Hallmark tests – primary testing you would do with the expected abnormal results: This encompasses the specific diagnostic tests and examinations routinely employed to confirm the presence of the disease. The choice of tests may vary based on the suspected condition and typically includes laboratory tests, imaging studies, or biopsies that yield characteristic abnormalities associated with the disease.

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Description

Test your knowledge on lower and upper motor neuron lesions, disc prolapse, and related symptoms. This quiz covers key characteristics, imaging techniques, and typical outcomes associated with spinal disc issues. Perfect for students studying neurology or physical therapy.