3: PIVD and mechanical backache Flashcards
What is a major aspect of the social history in someone with mechanical back pain?
Occupational history
What are some neurological symptoms associated with back pain?
Numbness
Pins and needles
Weakness
Bowel / bladder changes? think cauda equina
What are some red flag features of back pain?
Non-mechanical pain
Systemic symptoms (fever, nausea, weight loss, night sweats…)
New neurological symptoms
Saddle anaesthesia / bowel / bladder symptoms (cauda equina syndrome)
History of cancer
History of steroid use
What is saddle anaesthesia?
Anaesthesia limited to buttocks, thighs and perineum
major symptom of cauda equina syndrome
What does Schober’s method measure?
Lumbar spine flexion
What is the reference point for Schober’s test?
Sacroiliac dimples
What spinal movements is a patient asked to perform during a spine assessment?
Flexion
Extension
Lateral flexion
What is assessed during a neurological examination re: the spine?
Myotomes
Dermatomes
Reflexes
Nerve irritation
Which reflexes are tested during a neuro exam?
Knee jerk (L3/4)
Ankle jerk (L5)
Plantar reflex
How is sciatica tested for?
Leg raise
Aims to irritate nerves causing leg pain
What is the femoral stretch test used to elicit?
Upper leg nerve pain
Which nerve is affected in sciatica?
Sciatic nerve
L4 - S3
Are X-rays used to diagnose causes of back pain?
No, they usually don’t help much
Cause anxiety because irrelevant abnormalities will appear on the report
What is the gold standard investigation for back pain?
MRI scan
Which joints are commonly involved in back pain?
Which investigation can be done to check this?
Facet joints
Diagnostic facet injection with analgesia to see if symptoms improve
What type of joint are facet joints?
Synovial joints
What is sciatica?
Buttock / leg pain in dermatome of sciatic nerve with neurological disturbance
What spinal pathology causes a variety of different diseases?
Disc prolapse
What is the normal presentation of disc prolapse?
Episodic back pain
then
Leg pain and neuro symptoms (sciatica) affecting specific myotomes and dermatomes
Is disc prolapse an medical emergency?
No, unless it’s cauda equina syndrome
Do all disc prolapses require surgery?
No, most settle themselves
At what age do people tend to get disc prolapses?
30s - 50s
So if it’s not settling within 3 months it’s likely to severely disrupt their life
If a patient’s disc prolapse isn’t resolving within 3 months, what is the next step?
Spinal surgery
How is backache treated conservatively?
Bed rest for a short time
Simple analgesics, NSAIDs and muscle relaxants
Then mobilise the patient, physiotherapy, pain clinic, complementary therapy
How many patients with back pain are suitable for surgery?
Very very few
What is a progressive complication of facet fusion surgery?
Adjacent segment disease
Fusion spreads up to multiple levels - increasingly poor flexibility
Factors like diagnosis, patient health and demographic actually matter little in terms of adverse factors for spinal surgery.
What are some significant adverse factors?
Yellow flags of back pain:
Patient is undergoing litigation
Disputes with government re: benefits
Chronic pain syndrome / behaviour
