Back pain Flashcards
Red flags
- Age less than 18 and more than 55 yrs old
- Night pain at rest
- Previous hx of infection or Ca
- Systemic symptoms
- Cauda equina symptoms
- Widespread neurology
- Thoracic back pain
- Steroid or IVDU
How long do you have to be taking steroid for
Oral steroids for 3 months, not including inhalers
Yellow flag signs
Psychosocial factors associated with poorer outcomes
- fear avoidance - reduce activity in fear it will make back worse
- whiplash or work claim
- negative attitude that back pain is harmful and will not get better
- unwillingness to do physio, wanting a quick fix
- low mood and social withdrawal
Causes of back pain
Mechanical:
- Strain/idiopathic
- Trauma
- Pregnancy
- Disc prolapse
- Spondylolisthesis
Degenerative: spondylosis, vertebral collapse, stenosis
Inflammatory: Ankylosing spondylitis
Neoplasm: Mets, myeloma
Infection: TB, abscess
Spondylolisthesis
Forward shift of one vertebra on another
Common places of disc prolapse
L4/L5
L5/S1
Nerve root lesions
L2:
- Hip flexion + adduction
L3
- Knee extension
- Hip adduction
- Reflex = Knee Jerk
L4:
- Foot inversion + dorsiflexion
- Knee extension
- Knee Jerk
L5
- Great toe dorsiflexion
- Foot inversion + dorsiflexion
- Knee Flexion
- Hip extension + abduction
S1
- Foot eversion
- Foot and toe plantarflexion
- Knee flexion
- Ankle Jerk
Ix of back pain
Usually only necessary if red flags present:
Bloods: FBC, ESR, CRP
ALP, PSA - mets
MRI - of whole spine
CT - fracture
Conservative Mx of back pain
- Max 2d bed rest
- Education: keep active, how to lift / stoop
- Physiotherapy - strengthen core muscles
- Psychosocial issues re. chronic pain and disability
- hot water bottle
Medical mx of back pain
Analgesia:
NSAIDs ± co-codamol
(opiods do not help)
Amitriptyline for neurological pain and sciatica
Muscle relaxant: low-dose diazepam (short-term)
Facet joint injections - steroid and pain relief
Surgical mx
Decompression
Prolapse surgery: e.g. microdiscectomy
Cauda equina symptoms
Painless urinary retention Bilateral sciatica Faecal and urinary incontinence Impotence Perianal numbness
Cancers that metastasise to spine
Prostate Breast Kidney Thyroid Lung
Infection of spine
Sharp intense back pain commonly after UTI
Caused by spondylodiscitis
RF: IVDU and steroids
Cauda equina
Group of lumbar and sacral spinal nerve roots that exit the spinal cord at L2
Cauda equina syndrome
Compression of the cauda equina commonly due to paracentral disc prolapse
Occurs in 30 - 50s
Decompress within 48 hours
Cauda equina syndrome presentation if not decompressed
Foot drop - L5
Manual evacuation and timed bowel movements
Catheter
Sexual dysfunction
UMN legion
Pathology in brain or spinal cord
UMN legion presentation
Hypereflexia Spasticity Clasped knife rigidity Atrophy of disuse Clonus - 5+ involuntary muscle spasms (Hoffman's in upper limb) Babinski's sign
Hoffman’s sign
Flick middle finger
Causes index finger DIP and thumb interphalangeal joint to flex
LMN lesion
Legion at ventral horn or brainstem and below
Presentation of LMN lesion
Fasciculations Paralysis Hypotonia Hyporeflexia Atrophy of denervation
Myelopathy
Conditions that affect the spinal cord
- stenosis
- normally cervical or lumbar
Cervical myelopathy
60+ yo
Due to degeneration so progressively get worse
- paraesthesia of hand and arm
- loss of fine motor movements - can’t do buttons
- Loss of balance
- Decreased ROM and cervical neck pain due to OA
Mx: requires surgery
Radiculopathy
Compression of nerve roots
Sensory, motor or mixed
Bladder scan
Pre void and post void
Bladder normally holds 500ml
If retention:
Pre void - 400ml + residual
Post void - 200ml + residual
Spondylodiscitis on Xray
Takes 3 -4 weeks to show end plate changes on Xray therefore not usually done
