Approach to back pain Flashcards
1
Q
Learning Outcome:
A
- Mechanical
- PID
- spondylosis
- spondylolisthesis
- spinal stenosis
- scoliosis
- kyphosis
- trauma - Infection
- pyogenic osteomyelitis
- discitis
- tuberculosis
- epidural abscess - Inflammatory
- ankylosing spondylitis
- reiter’s syndrome
- psoriatic arthritis - tumors
- extradural: metastasis
- intradural: meningioma, lipoma, neurofibroma
- intramedullary: ependymoma, astrocytoma - vascular
- haematoma
2
Q
Pattern of neurological deficits
A
- Myelopathy
i. UMNL
- loss of motor level of injury and below
- hyperreflexia (babinski, BCR intact, inverted brachioradialis reflex, hoffman’s sign, jaw jerk)
- hypertonia (anal tone intact)
ii. somatosensory
- anterolateral: pain, temp, crude touch
- dorsal column: vibration, proprioception, fine touch
iii. autonomic
- bladder
- bowel
* weakness, paraesthesia, numbness
* pain less common than radiculopathy
* autonomic common - Radiculopathy
i. LMNL
- loss of motor usually at affected levels only (1-2 segments)
- hyporeflexia
- hypotonia
ii. Somatosensory
- anterolateral: pain, temp, crude touch
- dorsal column: vibration, proprioception, fine touch
iii. Autonomic
- rarely involve unless sacral nerve roots involved
*pain is more common than myelopathy, shooting
due to dura irritation
*weakness, tingling, paraesthesia
*autonomic rare
3
Q
Prolapse Intervertebral Disc pathology
A
- epids: 20-45 yo
- stages:
i. protrusion: bulging while annulus intact
ii. rupture: annulus rupture
iii. extrusion: bulges to either side of pll
iv. sequestration: part of nucleus in spinal canal or intervertebral foramen - compression area:
i. posterolateral: nerve root compression proximal to point of exit, upper (most common)
ii. central: cauda equina
iii. foraminal: involve existing nerve, lower
4
Q
Prolapse Intervertebral Disc diagnosis
A
Hx
- back pain (tearing of annulus fibrosis or pll)
- sciatica pain (disc irritates the dura of adjacent nerve roots)
- increase with stooping forward of lifting (compress disc)
- worse by coughing or straining
- associated with: weakness, numbness, paraesthesia
- if cauda: perineal numbness, urinary retention
Pe:
- listing to one side (avoid nerve root compression) depends bulge medial or lateral to nerve root
- knee slightly flex (relax tension on sciatic nerve)
- restricted back movement
- listing increase wih forward flexion
- tenderness in midline lower back, paravertebral spasm
- SLR: +ve
- bowstring test: +ve
- crossed sciatic tension: may be +ve
- femoral stretch test: +ve
- neurological: weakness, wasting, diminished reflex, dermatomal sensory loss
- L5: Knee flexion, big toe extension
- S1: Plantar flexion, eversion, depress ankle jerk, sensory loss lateral border of foot
- at most 2 levels are affected
X-ray:
- tro exclude bone disease
- osteophytes due to space narrowing
5
Q
Prolapse Intervertebral Disc management
A
- Rest: hips and knees slightly flex
- Reduction: best rest, traction for 2 weeks
- Removal:
i. indication
- persistent pain after conservative tx (failed 6 weeks)
- cauda equina
- neurological deterioration
ii. how
- laminotomy
- discectomy - Rehabilitation
- isometric exercise: how to sit, lie, bed and lift with least strain
6
Q
Spondylolisthesis pathology
A
- definition: forward translation of one segment of spine upon another
- epidemiology: 20 years old
- classification:
i. dysplastic (20%): defects in superior sacral facet. associated with spina bifida
ii. lytic/isthmic (50%): defects in pars interarticularis due to repetetive breaking and healing (spondylosis) (young)
iii. degenerative (25%): defects in disc or facet joints L4/L5 middle aged women, associated with osteoarthritis, crystal arthropathy (>50 yo)
iv. post traumatic
v. pathological (TB, Neoplasm)
7
Q
Spondylolisthesis diagnosis
A
Hx
- backpain
- intermittent
- onset after exercise or strain
- +/- sciatica
Pe
- flat buttocks
- transverse loin crease
- lumbar spine in front of sacrum
- step deformity
- hamstring tightness
X-ray
- lateral: forward shifting of vertebrae
- oblique: break in pars interarticularis
8
Q
Spinal Stenosis pathology
A
- definition: abnormal narrowing of the central canal, the lateral recesses or the intervertebral foramina to the point where the neural elements are compromised
- classification
i. central stenosis: spinal canal, cause myelopathy
ii. lateral stenosis: lateral recess or intervertebral foramen, cause radiculopathy - causes:
i. primary/congenital
- congenital vertebral dysplasia (fail segmentation, incomplete closure or arch)
- premature ossification of vertebral arch
- Paget’s disease (bone thickening)
ii. secondary/acquired
- spondylosis
- spondylolisthesis
- pid
- ossification of lig. flavum
- post-operative fibrosis
- tumors
- fractures - Narrowing area:
i. central canal: thecal sac, lig. flavum, facet joint
ii. lateral recess: superior facet, disc
iii. foraminal: facet enlargement, overriding, disc
9
Q
Spinal Stenosis diagnosis
A
Hx
- elderly >50
- pain, heaviness, numbness, paraesthesia of thighs, legs
- after standing upright (reduce interlaminar space) or walking 10-15mins (Mechanical comprrssion of nerve root -> venous congestion, diminisehd arterial flow -> decrease impulse conduction)
- relieved with bending forward (walking uphill)(increase by 12% in flexion), aggravated with extension (downhill) (decrease by 20% in extension)
X-ray
- midsagittal diameter (AP) <11mm
- interpedicular diameter (transverse) <16mm
- degenerative features
MRI
- Narrowing of spinal canal <10mm
11
Q
Acute Pyogenic Osteomyelitis diagnosis
A
Hx
- RF: immunodeficient, elderly, distant foci infection, spine procedures
- localised pain, intense, continuous
- associated with spasm, restricted movement due to pain
- sepsis: pyrexia
Pe
- inflammation sign
- pyrexia, tachycardia
Blood ix
- TWBC raised
- CRP, ESR raised
- anti-staphylococcal antibody titre (ASOT)
- blood culture
X-Ray
- loss of disc height
- irregularity of disc space
- erosion of vertebral end plate
- soft tissue swelling
MRI
- sensitive but not specific
Needle biopsy
- often organism not found
12
Q
Acute Pyogenic Osteomyelitis management
A
- Bed rest
- Analgesic
- IV antibiotics 4-6 weeks
- Monitor TWBC, CRP, ESR decline
- Nutritional support, control comorbidity
- At discharge:
- oral antibiotics 6-8 weeks
- spinal brace
- TCA, X-Ray: spontaneous fusion of infected vertebrae
++Operative tx
i. poor response to conversavative tx
ii. presence of neurological signs
iii. soft tissue abscess
13
Q
Discitis
A
- Epidemiology: rare
- Source: Iatrogenic:
- discography
- chemonucleolysis
- discectomy - Diagnosis:
- Hx of disc procedure
- Back pain, muscle spasm
- ESR elevation
14
Q
Spinal Tuberculosis pathology
A
- Epidemiology: most common site of skeletal TB
- Pathology:
i. start at vertebral body adjacent to disc (destruction, caseation): most commonly thoracic vertebrae
ii. discitis
iii. vertebral bodies collapse into each other, forming sharp angulation, progressive kyphosis (gibbus/khypos)
iv. vertebrae recalcify, bony fusion
++ paravertebral abscess
++ cord damage die to: pressure by abscess, bone sequestra, ischaemia from spinal art. thrombosis - Cx: Pott’s Paraplegia
i. early onset paresis:
- within 2 years
- stage of inflammation, cold abscess, caseation, sequestration
- good neurological recovery
ii. late-onset parasis:
- direct cord compression from increasing deformity, vascular cord insufficiency
- poor neurological recovery
15
Q
Spinal Tuberculosis diagnosis
A
Hx
- intermittent flares of backpain
- tb contact, diagnosed with tb
- cold abscess
- restricted spinal movement
- neurological: paraesthesia, leg weakness, incontinence
- night sweats, loa, low
Pe
- kyphosis
- spastic paraparesis
Ix
- mantoux test
- raised ESR
- raised lymphocyte
X-Ray
- narrowing of disc space
- bone destruction, collapse, fusion
- parasoinal soft tissue shadows (edema, abscess, swelling)
Needle biopsy
Spinal fluid analysis
MRI, CT
- involvement of cord compression, posterior vertebrae elements, paravertebral abscess, epidural abscess
16
Q
Spinal Tuberculosis management
A
Principles:
- Eradicate or arrest disease
- Prevent or correct deformity
- Prevent paraplegia
Pharmacological:
- 2 months aggressive: IR
- 10 months maintenance: IRPE
Surgery:
- indication:
i. neurological involvement not responding to pharma tx
ii. abscess
iii. threatened or severe kyphosis - how: debridement and decompression (anterior spinal fusion with strut graft)
