back pain

Question 1

what are the symptoms of neurogenic claudication?

Answer 1

pain, tingling, or cramping in the lower back and one or both legs, hips, and buttocks.

Weakness or heaviness in the legs may also occur. These symptoms are especially present when standing upright or walking and usually relieved with leaning forward or sitting down.

Question 2

what are red flags for back pain?

Answer 2

Spinal fracture (e.g., major trauma)

Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)

Spinal stenosis (e.g., intermittent neurogenic claudication)

Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)

Spinal infection (e.g., fever or a history of IV drug use)

Question 3

what does is the STarT tool for back pain used for?

Answer 3

to stratify the risk of a patient presenting with acute back pain developing chronic back pain.

Question 4

what are key red flags to ask about with caudal equine?

Answer 4

Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination

Question 5

what is the management for caudal equina?

Answer 5

Immediate hospital admission
Emergency MRI scan to confirm or exclude cauda equina syndrome
Neurosurgical input to consider lumbar decompression surgery

Surgery should be performed as soon as possible to increase the chances of regaining function. Even with early surgery, patients can be left with bladder, bowel or sexual dysfunction. Leg weakness and sensory impairment can also persist.

Question 6

how is metastatic spinal cord compression different to cauda equine?

Answer 6

MSCC presents similarly to cauda equina, with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.

Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). The nerves being compressed are lower motor neurons that have already exited the spinal cord.

When the spinal cord is being compressed higher up by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen.

Question 7

how is metastatic spinal cord compression treated?

Answer 7

High dose dexamethasone (to reduce swelling in the tumour and relieve compression)
Analgesia
Surgery
Radiotherapy
Chemotherapy