[31] Back Pain Flashcards
What causes mechanical pain of the back?
Soft tissue injury leads to dysfunction of the whole spine, which leads to muscle spasm and main
What may cause mechanical back pain?
An inciting event, e.g. lifting
Who should mechanical back pain be suspected in?
Younger patients with no sinister features
What is involved in the conservative management of mechanical back pain?
Max 2days bed rest Education - keep active, how to lift etc Physiotherapy Address psychosocial issues regarding chronic pain and disability Warmth
What is involved in the medical management of mechanical back pain?
Analgesia
Muscle relaxant
What analgesia is used in the medical management of mechanical back pain?
Paracetamol
NSAIDs
Codeine
What muscle relaxant is used in medical management of mechanical back pain?
Low-dose diazepam
What is the limitation of diazepam in the management of mechanical back pain?
It is only for short-term use
What happens in disc prolapse?
Herniation of nucleus pulposus through annulus fibrosis
Which nerve roots are most commonly compressed in disc prolapse?
L5 and S1
What disc prolapse compresses the L5 root?
L4/5
What disc prolapse compresses the S1 root?
L5/S1
How might disc prolapse present?
As severe pain on sneezing, coughing, or twisting a few days after a low back strain
What is lumbago?
Lower back pain
What is sciatica?
Shooting radicular pain down buttock and thigh
What are the signs of a disc prolapse on examination?
Limited spinal flexion and extension
Free lateral flexion
Lesague’s sign
What is Lesague’s sign?
Pain on straight-leg raise
What might a lateral herniation cause?
Radiculopathy
What might a central herniation cause?
Corda equina syndrome
What examination signs might be seen in a disc prolapse causing L5 root compression?
Weak hallux extension, with or without foot drop
Decreased sensation on the inner dorsum of the foot
How can foot drop due to L5 radiculopathy be distinguished from peroneal nerve palsy?
Weak inversion in L5 radiculopathy
What examination signs might be seen in a disc prolapse causing S1 root compression?
Weak foot plantarflexion and eversion
Loss of ankle-jerk
Calf pain
Decreased sensation over the sole of the foot and back of calf
How is a suspected disc prolapse investigated?
MRI
When does the MRI need to be done as an emergency in suspected disc prolapse?
If cauda equina
What is involved in the conservative management of a disc prolapse?
Brief rest
Mobilisation
Physiotherapy
What is involved in the medical management of disc prolapse?
Analgesia
Transforaminal steroid injection
In what % of patients is brief rest, analgesia, and mobilisation effective?
> 90%
What is involved in the surgical management of disc prolapse?
Discectomy or laminectomy
When might the surgical management of disc prolapse be required?
Cauda equina syndrome
Continuing pain or muscle weakness
What is the most common surgical procedure done for disc prolapse?
Lumbar microdiscetomy
What happens in a lumbar microdiscectomy?
Microscopic resection of the protruding nucleus pulposus
What approach is taken in a lumbar microdiscectomy?
Posterior approach, with the patient in the prone position
May be performed endoscopically
What is spondylolisthesis?
Displacement of one lumbar vertebra on another
What direction does spondylolisthesis usually occur?
Forward
What vertebra is usually affected in spondylolisthesis?
L5 onto S1
How can spondylolisthesis sometimes be detected?
May be palpable
What are the causes of spondylolisthesis?
Congenital malformation
Spondylosis
Osteoarthritis
When does spondylolisthesis present?
In adolesence or early adulthood
How does spondylolisthesis present?
Pain, worse on standing, with or without sciatia, hamstring tightness, and abnormal gait
How is spondylolisthesis diagnosed?
Plain radiography
How is spondylolisthesis managed?
Corset
Nerve release
Spinal fusion
What causes spinal stenosis?
Developmental predisposition, with or without facet joint osteoarthritis leads to generalised narrowing of lumbar spinal canal
How does spinal stenosis present?
Spinal claudication
Pain on spine extension
Describe the features of spine claudication
Aching or heavy buttock and lower limb pain on walking
Rapid onset
May come with parasthesia/numbness
Pain eased by leaning forwards
How is spinal stenosis investigated?
MRI
How is spinal stenosis managed?
Corsets
NSAIDs
Epidural steroid injection
Canal decompression surgery
What are the neurosurgical emergencies?
Acute cord compression
Acute cauda equina compression
What are the symptoms of acute cord compression?
Bilateral pain in the back and radicular area
LMN signs at compression level
UMN signs and sensory disturbance level below compression
Sphincter disturbance
What are the symptoms of acute cauda equina compression?
Alternating or bilateral radicular pain in legs
Saddle anaesthesia
Loss of anal tone
Bladder and bowel incontinence
How is acute cord compression/acute cauda equina compression managed if caused by large prolapse?
Laminectomy/discectomy
How is acute cord compression/acute cauda equina compression managed if caused by tumours?
Radiotherapy and steroids
How is acute cord compression/acute cauda equina compression managed if caused by abscesses?
Decompression
