UP TO CASE 3

CTS 1 – Back Pain and Lumbar Puncture

Case 1

Your car seems to have sprung an oil leak, so you take it to Salvu, the car
mechanic down the road. He tells you that he won’t be able to deal with it
till next week, as he has been off with a backache for a few days, and has a
lot of catch up work to do. As you are a second year medical student you
try to help by asking questions about the pain:

When did it start? (Last week)

Was it sudden or gradual? (Sudden)
What kind of pain is it? (Was a sharp pain, but now settled to a dull ache)
What exactly was he doing when he first felt the pain? (Pushing a car that
would not start)
Where is the pain exactly? (All over the lower back, but seems to be worse
on the right)
Does it shoot down the leg? (Yes)
Does coughing make it worse? (Yes)
Does he have any numbness or tingling in his leg or foot (Yes to both, over
the lateral part of the right leg, foot and little toe).
Has he ever had pain like this before? (Yes, many years ago after heavy
lifting, went away on its own).
Can he bend over to touch his toes (No, can only bend a few inches, limited
by pain in his back).

He shows you the doctor’s medical report which states that there is
diminution in the spinal lumbar curve and a tilt of the trunk to the left side.
He has marked limitation of movement in the lumbar vertebral column.
Raising his right extended leg is limited by pain to 20 degrees.
There is weakness in dorsi-flexion of his right foot as well as loss of sensory
perception over the dorsal aspect of the right foot. Animation

In cervical region the bones are smaller so the nerve comes straight out.
As we go down, the bone size increases and the spinal nerve goes down more
obliquely. So a lateral protrusion is likely to impinge on more than one nerves.

Each vertebral bone is protected by posterior longitudinal ligament so its

very unusual for disc to protrude backwards. So its more likely to protrude
sideways. If backwards protrusion occurs then there’s bowel incontinence
and paralysis of lower nerve.

Pattern- weakness in dorsiflexion of right foot, this is controlled by L5.

There is loss of sensation over dorsal aspect of right foot, this is L5 again.
This condition of protruding IV (intraverterbral disc) disc is common in
Lumbar and cervical region. The cervical and lumbar spine are very
mobile. This problem occurs in junction between a mobile and an immobile
vertebral region. If herniation is C8 you’d feel affect medial aspect of
fingers.
1. Think systematically of anatomical structures from which back pain might
arise.

Bone
Osteoporosis: no painful… hurts when bone gets fracture…
bone collapsed due to osteoporosis
malignancy: metastatic cancer in male spread from prostate.
scoliosis
tumour pressing on all the structures

Muscles
Muscle Pain… Strain, Sprains, Spasms

Joints
arthritis

Ligament
strain

Nerves
Herniated Disc…
Referred pain
Pancreas, kidney and other abdo strutures

Skin
herpes zoster in the back dermatome
spinal cord
IV DISC… irritation of the spinal nerve causes the problem.

endometriosis
Endometriosis is a common condition where tissue that behaves like the
lining of the womb (the endometrium) is found outside the womb.
 Infection
inflammation
sign is something as a healthcare profession going to elicit from the
patient something felt, observed.

Signs used to find which nerve route is affected

DERMATOMES… sensation
MYOTOMES… movement
REFLEXES

L5 nerve lesion:
due to distribution of the nerve…
also the movement.

Not S1 as performed ankle jerk is present

Not L4 as knee jerk is present

Cauda Equina L1/L2: routes of the nerve floating in CSF, which ends as
S1/S2.
the nerve routes will exit through the vertebrae.
L5 nerve route will exist between L5 and S1…

In humans, the spinal cord stops growing in infancy and the end of the spinal
cord is about the level of the third lumbar vertebra, or L3, at birth. By the time
adulthood is reached, because the bones of the vertebral column continue to
grow, the end of the cord is at the level of L1 or L2 (closer to the head).

Not common to have a pure L5 lesion as there are nerve routes running
down with L5 and they can become compressed as well in the process of
the dics herniating.

2. How do you explain that the pain shoots down the right leg?

Compression of the nerve root that supplies he right leg, deprives the
nerve of O2, thererofe whole nerve distribution is painful.
Probable a herniated disc compressing on the nerve roots which supply
the leg. Here the sciatic nerve is being compressed. This nerve is large
and its branches supply the muscles of the leg. The main nerve traveling
down the leg is the sciatic nerve. Pain associated with the sciatic nerve
usually originates higher along the spinal cord when nerve roots become
 compressed or damaged from narrowing of the vertebral column or from
a slipped disk. Symptoms can include tingling, numbness, or pain, which
radiates to the buttocks legs and feet.

3. Why does coughing seem to make the pain worse? Image

Coughing causes an increase in intrabdominal pressure  veins on post

ado wall, IVC  increase pressure in venous system, increase in CSF
pressure.

The cerebrospinal fluid (CSF) is produced from arterial blood by the choroid
plexuses of the lateral and fourth ventricles by a combined process of diffusion,
pinocytosis and active transfer.

Coughing also causes movement of all the chest wall muscles which are
attached to the back.

4. What movement might lessen the pain?

Standing up and extension

but Raising the extended leg: recumbent position… causes pain as you
are stretching the sciatic nerve : STRAIGHT LEG RAISING TEST.

5. How do you explain that

opens the spaces

6. Explain in anatomical terms the likely cause of his condition. Why is this
condition most common in the lumbar area? Video

Lumbar disc herniations are more common than cervical disc herniations.
The discs usually affected are those between the fourth and fifth
lumbar vertebrae and between the fifth lumbar vertebra and the sacrum.
In the lumbar region, the roots of the cauda equina run posteriorly over
several inter- vertebral discs. A lateral herniation may press on one or
two roots and often involves the nerve root going to the intervertebral
foramen just below. However, because C8 nerve roots exist and an
 eighth cervical vertebral body does not, the thoracic and lumbar roots
exit below the vertebra of the corresponding number. Thus, the L5
nerve root exits between the fifth lumbar and first sacral vertebrae.
Moreover, because the nerve roots move laterally as they pass toward
their exit, the root corresponding to that disc space (L4 in the case of
the L4 to 5 disc) is already too lateral to be pressed on by the herniated
disc. Herniation of the L4 to 5 disc usually gives rise to symptoms refer-
able to the L5 nerve roots, even though the L5 root exits between L5
and S1 vertebrae. The nucleus pulposus occasionally herniates directly
backward, and if it is a large herniation, the whole cauda equina may be
compressed, producing paraplegia.

An initial period of back pain is usually caused by the injury to the disc.
The back muscles show spasm, especially on the side of the herniation,
because of pressure on the spinal nerve root. As a consequence, the
vertebral column shows a scoliosis, with its concavity on the side of the
lesion. Pain is referred down the leg and foot in the distribution of the
affected nerve. Since the sensory posterior roots most commonly
pressed on are the fifth lumbar and the first sacral, pain is usually felt
down the back and lateral side of the leg, radiating to the sole of the
foot. This condition is often called sciatica. In severe cases, paresthesia
or actual sensory loss may be present.

Pressure on the anterior motor roots causes muscle weakness.

Involvement of the fifth lumbar motor root produces weak- ness of
dorsiflexion of the ankle, whereas pressure on the first sacral motor
root causes weakness of plantar flexion, and the ankle jerk may be
diminished or absent

slipped disc: tear in the outer fibrous part (annulos pulposus) in the
intervertebral disc nucleus pulposus herniates

7. What is the significance of the past history?

Due to the previous time he lifted and got groin pain there might have
been weakening of the annulos proprius.

8. Explain how it would be possible to distinguish between lesions at

different vertebral levels.
 L5 or S1

 motor exam
o ankle dorsiflexion (L4 or L5)
 test by having patient walk on heels

o EHL weakness (L5)

 manual testing
o hip abduction weakness (L5)
 have patient lie on side on exam table and abduct leg
against resistance
o ankle plantar flexion (S1)
 have patient do 10 single leg toes stands

9. What tests could be done to confirm the diagnosis? Would a plain X Ray,
CT scan, ultrasound or MRI of the spine be useful in this case? Anatomy
Spine

don’t need imagining, due to cost… 700E

the annulous fibrosis outside, nucleus pulposis inside which bulges out
when the former becomes weakened
when it bulges out, compresses nerves close by
so the nerves past it and at that level

would do MRI multiple nerves

MRI most accurate, to see the nucleus pulposus and annulosus

soft structures

Clinically made diagnois as already been made by D, M, and R.

use when multiple nerves involved or before surgery.
10. When might surgical treatment be indicated? What might surgery entail?

surgery when other measures don’t work, normally it would go away on its
own.

dissectomy: removal of herniated disc material that presses on the spinal

cord

11. Would your likely diagnosis change if the patient were:

a. An 80 year old woman? Fracture… Osteoporotic crushed fracture.
b. A 20 year old air conditioning fitter? Muscle/ligamentous
strain.../Trauma
c. A 30 year old nursery school teacher or babysitter? Muscle pain
due to lifting children/Shingles

Case 2

Your 15 year old brother woke up this morning sneezing and coughing,
complaining of a severe headache. Your mother takes his temperature and
its 104F. You can’t remember what this means in centigrade but can tell it’s
high. As you rush out the door to get to your 8 am lecture, you tell your
mum to call the doctor. When your GP arrives a few hours later, your
brother is restless in bed and looks ill. He is drowsy and responds slowly. His
pulse rate is 100 per minute. He has all the signs of an upper respiratory
infection but his chest is clear. He complains of severe headache which
extends from the neck to both sides of the head. As the doctor bends his
neck forwards, it appears to be stiff and he cries out in pain. Neurologic
examination is normal as is examination of the fundus of the eye with an
ophthalmoscope. The doctor suggests getting your brother to hospital right
away for tests. A lumbar puncture is done showing that the CSF pressure is
somewhat elevated, the fluid itself is clear, colourless and of normal protein
and cell count.
1. List the symptoms and signs in this case.

severe headache
40 degree fever
tachycardia 100/min [normal 60-100, Bradycardia <60]
drowsy, responds slowly
upper respiratory tract infection signs
stiff neck
csf pressure elevated

2. How do you explain the neck stiffness in this case?

meningitis
inflammation of the meninges, so when flex neck, more pressure on them,
more pain

3. Why was the fundus examined? Fundoscopy 1 Fundoscopy 2 Retina 1

Retina 2

Optic disc to see whether abnormality is due to raised intracranial

pressure, not clearly defined margins… PAPILOEDMA… optic disc is
swollen and is bulging forward.

Done before lumbar puncture because as doing a lumbar puncture will

reduce the ICP and may cause a brain herniation… taking CSF away from
a high pressure area, such as where the medulla which contains vital
centres  DEATH  known as CONING.

never take sample on elevated pressure

the fundus is the interior surface of the eye.

4. What is a lumbar puncture? Lumbar Puncture Guidelines

Collection of CSF from the spinal canal

can also be done to relieve intracranial pressure
5. What is the optimal site of lumbar puncture and why? How is this
identified? Videos

L3/L4 iliac crest

L3/L4, L4/L5,
good places as…
above… spinal cord ends, below - the sacrum is fused

SKIN  SUPERFICILA FASCIA (no musle in midline , erecto spinal on

side)  SUPRA/INFRA SPINOUS, LIGAMENTUM FLAVUM 
EPI/EXTRADURAL SPACE  DURA MATER  SUB DURA SPACE
 ARACHNOID  SUBARACHNOID SPACE  PIA

Feel 2 (resistant) gives… one in the ligamentous layer… then a second give
when through dura.

6. In what way does the anatomy of the lumbar vertebra facilitate entrance
of the needle into the spinal canal? What position should the patient be
in?

Lumbar vertebrae: spinoous processes are horizontal

Patientis usually placed in a left (or right) lateral position with their neck
bent in full flexion and knees bent in full flextion up to their chest…
like in a foetal position.

know you are in L3 as can feel both iliac crests in this postion

Blood in CSF: due to accidental puncturing of a vessel on the way in

(from the epidural space, where there are vessels) or blood in the CSF
(sub arachnoid haemmorhage…) therefore try again.
7. Are there any structures that may be injured by lumbar puncture below
the level of the cord? Where does the subarachnoid space end? Do you
think that it would be safer to carry out lumbar puncture in the upper
sacral region?

Sub arachnoid space end at S2

Upper sacral are fused

8. What structures are pierced by the needle before entering the

subarachnoid space? How can knowledge of this anatomy be used to help
the operator enter the correct space?

skin, (no muscles because its at the spine level, no muscle there),
superficial fascia (in obese people will have a lot of fat in it), supraspinous
and intraspinous ligaments, ligamentum flavum (called so because its
yellow), epidural space, dura matter, subdural space, arachnoid,
subarachnoid space (which is where we want to be as there is CSF), pia
mater, spinal cord

diff resistances diff tissues

in epidural space, blood, lymph, venous plexus
blood csf sample unclear
have to repeat
block holes with blood
to avoid headache

skin, superficial fascia, ligamentum flavum, epidural space (plexus of

vessels, lymphatics, fat), dura, subdural space,
arachnoid, subarachnoid space

(L3-S4 nerves come out at the level of end of spinal cord L1/L2, will be
painful if hit
cauda equina)

Spinal processes of Lumbar Bones are more horizontal.

9. Explain in anatomical terms the likely cause of his condition.

Meningitis
after a cold
do a lumbar puncture if you suspect something
10. What are the side effects and complications of lumbar puncture?

Headache  give fluids and pain relief… then seal of the leak due to
accidental holes being made in the dura, give patient their blood so can
coagulate their blood… known as blood patch.

Nausea  due to loss of CSF.

MENINGISM: irritation of the meninges

Case 3

Your girlfriend is having your first baby. She opts to have an epidural for
pain relief. You have read about lumbar puncture and you are concerned
about the safety of this procedure. You advise against it, but she tells you
that its safety and efficacy was extolled in the childbirth classes she has
been attending. You promise to attend the next class (about time too!) and
ask the midwife for advice.

epidural space
how to go through it
wouldn’t feel it
dont pierce dura
easy to do
works short time
as tip of catheter is in the epidural space

how manage to get into the space

put saline at end of needle
barrel contains air or saline, as can push

epidural
pain from labor: contraction of uterus
high up
at epidural, inject at L3/L4 or L4/L5 so put head down
might affect breathing, monitor

put in extra IV fluids

epidurals
disadvantages:
cannot pee, catheter
prolongs
decrease dose before birth

pros
wide awake
prolonged
1. Where is the epidural space?

In between the dura and the spinal canal

2. What does the epidural space contain and why is this relevant for lumbar
puncture?

Lymph, spinal nerve roots, loose fatty tissue (can cause problems as only
work on one side sometimes), arteries (with surrounding sympathetic
nerves, which can be blocked during anaesthtic, leads to drop in bp and
baby will become hypoxic), epidural venous plexus

3. How does the operator know that the epidural space has been reached?
Along with a sudden loss of resistance to pressure on the plunger of the
syringe, a slight clicking sensation may be felt by the operator as the tip
of the needle breaches the ligamentum flavum and enters the epidural
space.

Practitioners commonly use air or saline for identifying the epidural

space. However, evidence is accumulating that saline is preferable to air,
as it associated with a better quality of analgesia and lower incidence
of post-dural-puncture headache.

Need to stop before hitting the dura… and subarachnoid space. After
the first give.

If syringe at end of needle, hold thumb on syringe, and inject, will not
work.
But as you keep going you’ll be able to feel and inject.

4. In what way is an epidural anaesthetic differ from a spinal one?

Epidural: anaesthetic is in the epidural space

 Spinal: anaesthetic is in the subarachnoid space, has a finite time span…
Can continuously administer anaesthtic, after during the procedure.

5. How is epidural anaesthesia administered?

via a catheter

6. How is the height of the epidural block monitored?

Monitored by seeing if patients can move legs or not and whether pain is
gone.

7. What is caudal epidural anaesthesia?

use of a Tuohy needle, an intravenous catheter, or a hypodermic needle to puncture

the sacrococcygeal membrane.
 Injecting local anaesthetic at this level can result in analgesia and/or anaesthesia of
the perineum and groin areas. The caudal epidural technique is often used in infants and children
undergoing surgery involving the groin, pelvis or lower extremities

8. What are the advantages and disadvantages of epidurals?

Pro: rapid, effective pain relief. (so good you can do a c-section with it)
Con: Immobilised, medicalised delivery, lowers blood pressure

9. What are the advantages and disadvantages of spinals?

Same but last a fixed time

Difference from epidural anesthesia

Schematic drawing showing the principles of spinal anesthesia.

Epidural anesthesia is a technique whereby a local anesthetic drug is

injected through a catheter placed into the epidural space. This technique
has some similarity to spinal anesthesia, and the two techniques may be easily
confused with each other. Differences include:

 The injected dose for an epidural is larger, being about 10–20 mL in

epidural anesthesia compared to 1.5–3.5 mL in a spinal.
 In an epidural, an indwelling catheter may be placed that avails for
additional injections later, while a spinal is almost always a one-shot
only.
 The onset of analgesia is approximately 25–30 minutes in an epidural,
while it is approximately 5 minutes in a spinal.
 An epidural often does not cause as significant neuromuscular
block unless specific local anesthetics are used which block motor
fibres as readily as sensory nerve fibres, while a spinal more often does.
 An epidural may be given at a cervical, thoracic, or lumbar site, while a
spinal must be injected below L2 to avoid piercing the spinal cord.