Podcast
Questions and Answers
What is a common characteristic of lower motor neuron (LMN) lesions?
What is a common characteristic of lower motor neuron (LMN) lesions?
Which of these signs is indicative of upper motor neuron (UMN) lesions?
Which of these signs is indicative of upper motor neuron (UMN) lesions?
What is the likely outcome if the L4/L5 disc is affected?
What is the likely outcome if the L4/L5 disc is affected?
What is a common initial symptom reduction period for most disc prolapse cases?
What is a common initial symptom reduction period for most disc prolapse cases?
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Which stage of disc herniation is characterized by the inner disc pushing further into the outer layer without breaking through?
Which stage of disc herniation is characterized by the inner disc pushing further into the outer layer without breaking through?
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Which imaging technique may still show a bulging disc even after symptomatic resolution?
Which imaging technique may still show a bulging disc even after symptomatic resolution?
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Disc prolapse commonly occurs in which part of the spine?
Disc prolapse commonly occurs in which part of the spine?
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In cases of thoracolumbar syndrome, which nerves are implicated in referred pain to the buttocks and hip?
In cases of thoracolumbar syndrome, which nerves are implicated in referred pain to the buttocks and hip?
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What characterizes the progression from disc degeneration to a prolapsed disc?
What characterizes the progression from disc degeneration to a prolapsed disc?
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What is a recommended position to alleviate pain in disc prolapse patients?
What is a recommended position to alleviate pain in disc prolapse patients?
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Which neurological sign is most likely associated with upper motor neuron lesions?
Which neurological sign is most likely associated with upper motor neuron lesions?
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What is the typical time frame for resorption and symptomatic resolution in disc prolapse?
What is the typical time frame for resorption and symptomatic resolution in disc prolapse?
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What is the typical location where lumbar nerve roots exit the spine?
What is the typical location where lumbar nerve roots exit the spine?
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Which condition is characterized by irritation of the cluneal nerves?
Which condition is characterized by irritation of the cluneal nerves?
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Which symptom is NOT commonly associated with lateral spinal stenosis?
Which symptom is NOT commonly associated with lateral spinal stenosis?
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What is a hallmark test result expected in a patient with spinal stenosis?
What is a hallmark test result expected in a patient with spinal stenosis?
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What is a contraindicated treatment for disc prolapse?
What is a contraindicated treatment for disc prolapse?
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Which of the following conditions is a risk factor for developing spinal stenosis at an earlier age?
Which of the following conditions is a risk factor for developing spinal stenosis at an earlier age?
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Which factor may predispose an individual to facet and capsular irritation in thoracolumbar syndrome?
Which factor may predispose an individual to facet and capsular irritation in thoracolumbar syndrome?
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What type of symptoms are typically seen with central spinal stenosis?
What type of symptoms are typically seen with central spinal stenosis?
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Which condition can result from severe lumbar stenosis?
Which condition can result from severe lumbar stenosis?
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What are common aggravating factors for symptoms of lateral spinal stenosis?
What are common aggravating factors for symptoms of lateral spinal stenosis?
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What is the primary mechanism leading to spinal stenosis as a result of osteoarthritis?
What is the primary mechanism leading to spinal stenosis as a result of osteoarthritis?
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What type of weakness is commonly associated with lateral spinal stenosis?
What type of weakness is commonly associated with lateral spinal stenosis?
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Flashcards
Lateral Spinal Stenosis
Lateral Spinal Stenosis
Compression of the nerve root as it exits the spinal canal, typically causing unilateral symptoms.
Foraminal Spinal Stenosis
Foraminal Spinal Stenosis
Compression of the nerve root within the intervertebral foramen (IVF), often mimicking lateral stenosis.
Central Spinal Stenosis
Central Spinal Stenosis
Compression of the spinal cord within the spinal canal, usually causing bilateral symptoms.
Cauda Equina Syndrome
Cauda Equina Syndrome
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Osteoarthritis
Osteoarthritis
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Synovial Cysts
Synovial Cysts
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Facet Joint Hypertrophy
Facet Joint Hypertrophy
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Bone Spurs (Osteophytes)
Bone Spurs (Osteophytes)
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Disc Prolapse Natural History
Disc Prolapse Natural History
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Disc Prolapse Treatment Goals
Disc Prolapse Treatment Goals
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Rotatory Adjustments and Disc Prolapse
Rotatory Adjustments and Disc Prolapse
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What is Thoracolumbar Syndrome?
What is Thoracolumbar Syndrome?
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Cluneal Nerves and TLS
Cluneal Nerves and TLS
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TLS Pathophysiology (Maigne's Syndrome)
TLS Pathophysiology (Maigne's Syndrome)
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Why is the Thoracolumbar Junction Unstable?
Why is the Thoracolumbar Junction Unstable?
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Facet Joint Orientation in Thoracolumbar Syndrome
Facet Joint Orientation in Thoracolumbar Syndrome
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What is the corticospinal tract?
What is the corticospinal tract?
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What is the cauda equina?
What is the cauda equina?
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What is the dural sac?
What is the dural sac?
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What is a disc prolapse?
What is a disc prolapse?
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What is Stage 1 disc degeneration?
What is Stage 1 disc degeneration?
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What is Stage 2 disc herniation?
What is Stage 2 disc herniation?
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What is the intervertebral foramen?
What is the intervertebral foramen?
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What is the most common location for lumbar disc prolapse?
What is the most common location for lumbar disc prolapse?
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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
- Maigne's syndrome:
- 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
- Case studies – suggest that conservative care may help
Spinal Stenosis
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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
- Osteoarthritis
-
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.
