Back Anatomy and Management of Slipped Disc Flashcards
What are the different forms of back pain?
Non specific low back pain: pain not due to any specific underlying disease that can be found.
Mechanical low back pain: pain after abnormal stress and strain on the vertebral column.
Sciatica: pain radiating to the lower limbs with or without neurological symptoms
What is the most common cause of back pain?
Mechanical 90%. Causes: disc degeneration, disc herniation, annular tears, facet joint osteoarthritis, instability
What are other causes of back pain?
- Tumour including myeloma
- Infection - most common is S. aureus disc space infection followed by Tuberculosis (diagnosed very late and if left to point of vertebral collapse, person rendered paraplegic/quadraplegic instantly.)
- Spondyloarthropathy - inflammatory joint diseases
- Pars interarticularis injury - stress fracture in facet joints in young people. Must treat with rest or will get a full fracture with unstable spine for life.
- Compression fracture - affects old people with osteoporotic softening.
- Visceral - referred back pain from abdomen
What are indicators for sciatica?
- Unilateral leg pain greater than low back pain
- Pain radiating to foot or toes
- Numbness and paraesthesia in same distribution
- Straight leg raising test induces more leg pain
- Localised neurology - limited to one nerve root
What is NICE guidance for imaging?
- Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.
- Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.
- Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.
What are conservative treatment options?
Analgesia (Paracetamol) Anti-inflammatory drugs Manipulation Acupuncture Massage Allow some time to pass Bed rest does not result in faster recovery Most patients get better spontaneously
What are red flag symptoms for lower back pain?
Weight loss
Fever
Night pain - pain from tumour infection worse at night. Gets better when standing as fluid is squeezed out
Under 19 years
What are red flag symptoms for leg pain and their sensitivities?
Bowel or bladder dysfunction - 0.69
Saddle anaesthesia - 0.27
Profound neurological deficit - 0
What are the 4 risks of waiting too long?
- Metastases - early diagnosis may not affect prognosis. Risk of catastrophic fracture and paralysis - onset of symptoms to referral median time is 3 months. Bone replaced by black on T1 imaging.
- Inflammatory arthropathy - early diagnosis for effective treatment with biologics. Investigate under 35s after 3 months pain. Annulus of disc inserts into bone so shiny corner of bone appears in enthesis. Affects younger people and has lifetime morbidity but is made much better by treatment with biologic agents.
- Myeloma - Early diagnosis will catch disease at a more easily treated stage. Mean delay in diagnosis - interquartile range 84 to 306 days. Never cured but can become dormant
- Tuberculosis of spine - early diagnosis essential to effective treatment. 4 to 11 months delay in diagnosis. Bone appears white on MRI indicating fluid (pus) within, destroying the bone.
What are the imaging options for lower back pain?
MRI primarily. Radiographs and CT are secondary investigations.
What are the pros and cons of radiographs?
Cheap
Readily available
Traditional
Radiation
Overlook most important diseases
What does colouring in MRI mean?
CSF appears as white but when suppressed, appears black. Bone can appear a mixed colour if haemopoeitic and containing fat (marrow), especially post illness when haemopoeisis occuring at higher rate.
Describe T1 imaging in MRI
T1 images can be thought of as a map of proton energy within fatty tissues of the body. Highlights fat as white which includes subcutaneous fat (SC fat) and bone marrow of the vertebral bodies. CSF) contains no fat so it appears black on T1-weighted images.
Describe T2 imaging in MRI
T2 images are a map of proton energy within fatty AND water-based tissues of the body. CSF appears white here but bone cortex is black – it gives off no signal on either T1 or T2 images because it contains no free protons.
What is a consequence of a degenerate slipping disc?
Neural foramen provides space for spinal nerve to leave and is surrounded by fat. If bone slips, compresses the neural foramen which causes pain as nerve root compressed. Back exercises help as strengthen the muscles which stops bones sliding around, diminishing the pain.
