Back Pain

Question 1

How is pain communicated to the pain?

Answer 1

Mechanoreceptros

Spinothalamic tract

Fast route for sharp pain - Adelta fibres

Slow route for dull pain - C fibres. Travels via reticular formation, amygdala and cingulate cortex

Synapse at dorsal horn and decussate

Third neurone begins at thalamus

Question 2

What could be causing lower back pain?

Answer 2

Vertebra
Spinal cord
Nerve roots
Lumbar muscles

Referred pain:
Aorta
Kidneys
Pancreas

Question 3

What is radiculopathy?

Answer 3

Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve.
Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy).

Question 4

What is cauda equina syndrome?

Answer 4

Cauda equina syndrome is a rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed.

Question 5

What is mechanical back pain?

Answer 5

Mechanical pain is the general term that refers to any type of back pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating, and incorrect bending and lifting motions.

Question 6

What is radiculopathy?

Answer 6

Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve.

Unilateral symptoms

Most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy)

Question 7

If the spinal body is damaged, what happens?

Answer 7

Multiple symptoms in multiple spinal roots

Question 8

What causes radiculopathy?

Answer 8

Nucleus pulpous herniates posteriorly and laterally

‘Slipped disc’
Affects spinal root

Question 9

What is sciatica?

Answer 9

Describes radiculopahty of the scatic nerve

Shooting pain down the back of one leg

Question 10

What causes cauda equina?

Answer 10

Compression of the cauda equina that begins at L1/L2 level of spinal column

Most commonly due to disc herniates posteriorly and centrally you get bilateral symptoms

Infection

Tumor

Question 11

What does Paul have?

Answer 11

Cauda Equina Syndrome

Question 12

What are the most common sites of nerve compression in CES?

Answer 12

L4/L5

L5/S1

Question 13

What are symptoms of CES?

Answer 13

Bilateral symptoms
Bladder retention
Bilateral leg weakness
Change in bladder function
Reduced perineurial function (thighs, anus)
Sexual dysfunction
Anal tension

Question 14

What are the next steps with cauda equina?

Answer 14

Urgent MRI
Discussion with neurosurgeon
Need operating on within 24 hours of symptom onset

Question 15

Why did Paul have back pain for years and then a more sudden onset?

Answer 15

Cauda equina is indeed an acute issue. However, the size of the disc herniation required to actually compress the cauda equina is quite large. As a result, many patients start off with a small disc bulge with associated symptoms- e.g radiculopathy. However, the disc herniation can become bigger either gradually over time or suddenly which leads to cauda equina syndrome


Question 16

What is the difference between cauda equina and radiculopathy?

Answer 16

radiculopathy - often chronic slowly progressive managed usually conservative and on occasions mini-invasive surgery dependent on signs/symptoms/pain intensity

cauda Equina - large block of nerves affected , acute (or acute on chronic) presentation and an EMERGENCY as affecting crtical nerves S234 - pelvic/bladder nerves


Question 17

What is the progression of urinary function in cauda equina?

Answer 17

Changes in urination
Urinary intention
Overflow incontinence - pressure

Question 18

What are the red flag symptoms for cauda equina?

Answer 18

Saddle numbness
Sexual dysfunction
Urinary retention
Bilateral sciatica
Neurological deficit of the legs
Loss of anal tone or impaired sensation on rectal examination

Question 19

What are some neurological deficits of the legs?

Answer 19

Major motors weakness with knee extension
Ankle eversion
Foot dorsiflexion

Question 20

What are the early warning signs for Cauda Equina syndrome?

Answer 20

Loss of feeling/pins and needles between inner thighs or gentials

Altered feeling when using toilet paper to wipe yourself

Increasing difficulty when trying to urinate

Increasing difficulty when you try to control flow of urine

Change in ability to achieve erection or ejaculate

Loss of sensation in genitals during sexual intercourse

Question 21

What are some questions you can ask to diagnose cauda equina?

Answer 21

When was the last time you passed urine?

Have you noticed any changes when you have been intimate?

Question 22

What must you do when someone comes in with back pain?

Answer 22

Tell them you think its mechanical back pain

But if they experience any of these symptoms they must see an doctor

Need to give them the relevant information

Question 23

Where do surgeons make the incision in CES surgery?

Answer 23

Right over the area where the disc has herniated

Question 24

What are pain receptors called?

Answer 24

Noiciception receptors
Embedded on the cell membranes on high threshold neurons
Found on plasma membrane

Question 25

What causes muscle injuries?

Answer 25

Indirect or direct trauma

Question 26

What is the difference between strain and sprain?

Answer 26

Strain is an injury to the muscle or musculotendinous junction, whereas sprain is an injury to the ligament

Question 27

What are the causes of join swelling?

Answer 27

Infectious arthritis
Immune-mediated arthritis
Non-infectious and non-immune-mediated inflammatory arthritis
Paraneoplastic arthritis
Neoplastic arthritis.

Question 28

What are differentials for an acutely swollen joint?

Answer 28

Septic arthritis
Crystal arhropathies
Osteoarthritis
MSK injury
Spondyloarthropathies e.g. reactive, psoriatic arthritis

Question 29

What are differentials for muscle pain?

Answer 29

Medications e.g. statins
Strain/Sprain
Exertion 
Viral infections e.g. dengue
Vascular