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MSK > 1- back pain, spinal deformity & red flags > Flashcards

1- back pain, spinal deformity & red flags Flashcards

1
Q

what length of back pain is it then called chronic?

A

more than 3 months

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2
Q

what are areas where back pain is felt?

A
  • neck (cervical pain)
  • middle back
  • lower back (most common)
  • tailbone
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3
Q

what are intrinsic causes of back pain?

A
  1. spinal MSK system (most common cause)
  2. neurological system
  3. haematopoietic system
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4
Q

what are extrinsic causes of back pain?

A
  1. extrinsic MSK system
  2. neighbouring viscera
  3. neurological system (not local)
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5
Q

what are common causes of back pain?

A
  1. degenerative (sprain, disc disease, spinal stenosis)
  2. vascular (aortic dissection, spinal SAH)
  3. neoplasm
  4. infection
  5. inflammation (ankylosing spondylitis)
  6. trauma
  7. metabolic disorder (crystal deposition diseases like gout)
  8. neighbouring viscera
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6
Q

what are back pain red flags?

A
  • neurological deficit (numbness or weakness)
  • history of cancer
  • systemic features like fever, chills, night sweats
  • IV drug use
  • immunosuppression
  • trauma
  • osteoporosis
  • thoracic back pain
  • pain at rest & night
  • age <50yrs or <16yrs
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7
Q

what type of back pain might indicate neoplasm?

A

severe unrelenting pain, nocturnal pain, unrelieved by bed rest

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8
Q

what is low back pain examination?

A

LOOK, FEEL, MOVE

Look = deformity, curvature

Feel = spine, paraspinal musculature, SIJ

Move = flex, extend & lateral bend spine & hip

Tests - SLR, FABER (test for hip arthritis), neurological exam (power, tone, reflexes), vascular exam

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9
Q

what are causes of degenerative neck pain?

A

cervical spondylosis, cervical radiculopathy, cervical myelopathy

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10
Q

what are causes of infection causing neck pain?

A

discitis, osteomyelitis, epidural abscess

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11
Q

what are causes of inflammation causing neck pain?

A

rheumatoid arthritis, psoriatic arthritis

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12
Q

what viscera problem can cause neck pain?

A

carotid dissection

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13
Q

what symptoms can be meningitis?

A

headache, fever, stiffness, neck pain = red flag

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14
Q

what are provocative neck pain tests?

A

spurlings arm compression, overhead abduction relief

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15
Q

what are red flag emergencies for back pain diagnosis?

A
  1. Traumatic fracture or dislocation
  2. Cauda equina syndrome
  3. Acute foot drop
  4. Acute cord compression
  5. Spinal infection
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16
Q

what are some common risk factors for spinal fracture?

A
  • elderly patients
  • osteoporosis
  • long term steroid use
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17
Q

what is assessed during an upper limb and lower limb neurology exam in spinal injury?

A
  • motor function
  • sensory function
  • reflexes

= this helps identify any nerve damage

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18
Q

what are upper motor neuron signs that should prompt further assessment in back pain?

A
  • Hyperreflexia = exaggerated reflexes
  • Spasticity= increased muscle tone leading to stiffness
  • Positive Babinski sign = big toe extends upwards when sole foot stroked
  • Clonus = involuntary, rhythmic muscle contractions following a sudden stretch of muscle
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19
Q

what is cauda equina syndrome?

A

“Dysfunction of multiple lumbar & sacral nerve roots”

caused by - cauda equina compression from large central herniated lumbar disc prolapse, tumour, etc. and non-compressive aetiology – polyradiculopathy, post RT, vascular, AS etc.

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20
Q

what are typical features of cauda equina syndrome?

A

urinary retention, urinary or faecal incontinence, saddle anaesthesia

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21
Q

what is acute foot drop?

A

red flag of back pain where weakness of ankle dorsiflexion - you grade muscle weakness out of 5

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22
Q

what is acute cord compression?

A

sudden & severe compression of spinal cord resulting in rapid onset of neurological symptoms like severe weakness/numbness of extremities
= it’s a red flag

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23
Q

what is spinal osteomyelitis?

A

infection of the vertebrae, typically caused by bacteria (most commonly Staphylococcus aureus), though fungal infections can also be a cause. This condition can result in the destruction of vertebral bone tissue and, if left untreated, may lead to severe complications such as spinal abscesses, vertebral collapse, or even spinal cord compression.

24
Q

who is at risk for spinal osteomyelitis?

A

IV drug users, recent infection, recent spinal surgery or epidural catheter placement

25
Q

what are 3 types of spinal deformity? (common ones)

A
  1. scoliosis
  2. kyphosis
  3. spondylolisthesis
26
Q

what is scoliosis?

A

spinal deformity with sideways or coronal curve. also associated with vertebral rotation

27
Q

what are ways scoliosis may present?

A
  • may be able to visibly see
  • pain (not common feature of scoliosis)
  • sideways listing
  • prominent rib hump
  • asymmetry of shoulders (1 shoulder lower than the other)
28
Q

what are causes of scoliosis?

A
  • idiopathic
  • congenital
  • neuromuscular disease (associated with CP etc)
  • unequal leg length (can cause scoliosis)
  • degeneration
  • connective tissue disease
  • spinal tumour
  • spinal pain
29
Q

what are ways to classify scoliosis?

A

aetiology or age

30
Q

what are age classifications of scoliosis?

A
  • congenital
  • juve
  • adoloscent idiopathic scoliosis (10-18yrs)
  • adult onset
31
Q

what is involved in assessment of scoliosis?

A
  1. detailed history
  2. MSK spine exam and UL + LL neurological exam
  3. test = bend forward to look for rib hump (Adams test)
  4. refer to spinal deformity service
  5. whole spine X-ray (AP and lateral)
  6. may need MRI if atypical features
32
Q

what is the management of scoliosis?

A

→depends on skeletal maturity, severity of deformity & progression of deformity

  • observation
  • bracing
  • operation (usually avoided for children who are not finished growth)
33
Q

what is kyphosis?

A

spinal deformity with excessive convex curvature of spine, involving thoracic spine (commonly see stoop when walking)

34
Q

how does kyphosis present?

A
  • it’s a sagittal deformity, seen from inspecting patient from side

*note = thoracic spine is naturally kyphosed. kyphosis means hyper/excessive kyphosis

35
Q

what are causes of kyphosis?

A

Scheuermann’s disease (developmental disorder) , osteoporosis with wedge fractures

36
Q

what is spondylolisthesis?

A

spondylos = spine or vertebra
listhesis = slip

  • it’s anterior subluxation one vertebra on another (another sagittal spinal deformity)
37
Q

what are classifications of spondylolisthesis based on?

A

can be based on aetiologies or degree of slip (meyerding grading)

38
Q

what is management of spondylolisthesis?

A

usually manage limb symptoms like treat leg pain with decompression and fusion

39
Q

what are 2 main types of cervical spine problems?

A
  1. cervical radiculopathy
  2. cervical myelopathy
40
Q

what is cervical radiculopathy?

A

radiculopathy = nerve being pinched at root

so in this case in cervical region

41
Q

how would cervical radiculopathy present?

A
  • pain radiating from neck down into arm
  • numbness and/or weakness in upper extremities
42
Q

what are causes of cervical radiculopathy?

A
  1. cerebral disc prolapse
  2. vertebral osteophytes (bony lumps)
  3. other compressive lesions like tumours
43
Q

what are nerve root syndromes (types of cervical radiculopathy?)

A
  1. C5 from C4/5 disc. rare. pain radiates to shoulder. biceps reflex
  2. C6 from C5/6 disc. 20%. Pain radiates to thumb, lateral forearm. Brachioradialis reflex
  3. C7 from C6/7 disc. 70%. Pain radiates to fingers 2&3. Triceps reflex
  4. C8 from C7T1 disc. 10%. Pain radiates to fingers 4&5. Finger reflex
44
Q

what is cervical myelopathy?

A

myelopathy →inflammation/arthritis etc causing compression of spinal cord

so at cervical region

45
Q

how does cervical myelopathy present?

A
  • history of slow progressive symptoms like clumsiness of hands & feet, mild gait disturbance, paraesthesia of upper&lower extremities
  • later symptoms of loss of coordination, changes in gait & stiffness
  • change in bowel & bladder function

*makes sense that starts slow as something progressively growing & constricting

46
Q

what are causes of cervical myelopathy?

A
  1. disc osteophyte complex
  2. ligamentous hypertrophy
  3. degenerative spondylolisthesis
  4. other compressive lesions like tumours
47
Q

what can cause lumbar disc herniation, lumbar stenosis and spondylolisthesis, and degenerative scoliosis?
hint = 3 things that can happen and in combination lead to above

A
  1. disc - disc desiccation, annular tears, disc bulge, disc prolapse, disc fibrosis & resorption
  2. facet joint - hypertrophy, effusions & laxity
  3. ligamentum flavum hypertrophy
48
Q

what is lumbar disc herniation?

A

= when a soft cushion of tissue between the bones in your spine bulges outwards (slipped disc)

= can be asymptomatic

49
Q

what can lumbar disc herniation cause?

A
  1. lumbar radiculopathy
  2. cauda equina (dysfunction of multiple lumbar & sacral nerve roots)
50
Q

how does lumbar radiculopathy present?

A

pain radiating into leg. numbness & weakness. pain constant. worse with WB, valsalva & SLR

51
Q

how does cauda equina present?

A

urinary retention, urinary & faecal incontinence, saddle anaesthesia. lumbar radiculopathy features also seen a lot

52
Q

what is saddle anaesthesia?

A

a loss of sensation in the buttocks, perineum, and inner thighs

53
Q

what are types of lumbar stenosis?

A
  1. central stenosis = compression of all nerve roots passing through
  2. lateral recess stenosis = compression of transiting nerve root
  3. foraminal stenosis = compression of exiting nerve root
54
Q

what causes lumbar stenosis?

A

facet & ligament hypertrophy, additional spondylolisthesis in some

55
Q

how does lumbar stenosis present?

A

stenosis tends to present with claudicant leg pain, worse when walking/prolonged standing. relieved upon flexion of spine

56
Q

how would you assess back pain in physical exam?

A

Look = how patient walks in & out, deformity

Feel = spinal tenderness, paravertebral muscles, get patient to show where

Move = flexion, extension, lateral flexion →SLR, tone, power, reflexes, sensation in legs

57
Q

what is TUNA FISH mnemonic for red flags of back pain?

A

T = trauma

U = unexplained weight loss

N = neurological symptoms

A = age >50

F = fever, feeling unwell

I = immunocompromise (e.g. HIV)

S = steroids (for prolonged time)

H = history of carcinoma (breast, bronchus, prostate)

MSK (3 decks)

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