Back Pain Flashcards
What is vertebral osteomyelitis?
Infection of the vertebrae
What is the aetiology of vertebral osteomyelitis?
- Mostly haematogenous, most commonly staph. aureus
- May be associated with abscess - epidural, psoas
- As the vertebral end plates weaken, vertebrae may collapse leading to kyphosis or vertebra plana (flat vertebra) and disc space may reduce
What are the risk factors of vertebral osteomyelitis?
- PWID
- Poorly controlled diabetes
- IV site infections
- GU infections
- SSTI
- Post operative
- Primary bacteraemia in the elderly
What is the presentation of vertebral osteomyelitis?
Patients present with insidious onset of back pain (most commonly lumbar) which is constant and unremitting
- Paraspinal muscle spasm
- Spinal tenderness
- May have fever and/or systemic upset
- Severe cases may have an associated neurological deficit
What are the investigations of vertebral osteomyelitis?
- Bloods - raised CRP
- MRI - extent of infection and any abscess formation, imaging psoas sign indicates spondylodiscitis
- Blood cultures may indicate the causative organism (usually Staph. aureus including MRSA but atypical infections can occur in the immunocompromised)
- Consider endocarditis - look for clubbing, splinter haemorrhages, murmur, consider ECHO
What is the management of vertebral osteomyelitis?
- High dose IV antibiotics after CT guided biopsy to obtain tissue culture
- Antibiotics may be required for several months and response is assessed clinically and by serial CRP
- Around half of all patients go on to spontaneous fusion and resolution
Surgery
- Indications for surgery include inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit
- Surgery involves debridement, stabilization and fusion of adjacent vertebrae
What is Pott disease?
vertebral body osteomyelitis and intervertebral discitis from tuberculosis (TB)
What is the aetiology of vertebral TB?
- 1/2 have skin and soft tissue infection
- Less than half have pulmonary TB
- Immunosuppression/HIV
What is the presentation of vertebral TB?
- Often no systemic symptoms
- Clinical presentation is characteristically slow and insidious
- Back pain
- Lower limb weakness/paraplegia
- Kyphotic deformity
What are the investigations of vertebral TB?
- Imaging - x-ray, MRI
- Check for immunosuppression/HIV
What is the management of vertebral TB?
- Imaging - x-ray, MRI
- Check for immunosuppression/HIV
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms
What is the aetiology of mechanical back pain?
- Presents 20-55
- Obesity
- Poor posture
- Poor lifting technique
- Lack of physical activity
- Depression
- Facet joint OA
- Degenerative disc prolapse
- Spondylosis - where the IV discs lose water content with age, resulting in less cushioning and increased pressure on the facet joint which can lead to secondary OA
What is the presentation of mechanical back pain?
- Pain in lumbosacral region, buttocks and thighs
- Leg pain will be referred in nature (dull, gnawing, ill-defined) and rarely below the knee
- Mechanical pain - varies with time and activity
- Patient well with no ‘red flag’ symptoms
- Patient tends to have had several previous ‘flare ups’
What is the management for mechanical back pain?
- Advice:
- Try walk 30 mins a day
- If not possible - comfortable period of time, repeated to try and build up to 30 mins
- Try to stay at work
- Restrict rather than avoid activity
- Weight control if overweight
- Try walk 30 mins a day
- Analgesia - NSAIDs first line, add weak opiates if needed
- Physiotherapy
- Prognosis good - 90% better in 6 weeks
- Spinal stabilization surgery is controversial
What is an acute disc tear?
An acute tear can occur in the outer fibrosis of an intervertebral disc which classically happens after lifting a heavy object (e.g. lawnmower)
What is the presentation of an acute disc tear?
Pain is characteristically worse on coughing - coughing increases disc pressure
What is the investigation for an acute disc tear?
MRI
What is the management of acute disc tear?
- Analgesia and physiotherapy
- Symptoms usually resolve but can take 2-3 months to settle
What is sciatica?
Characteristic pain felt in the lower back, buttocks and the posterior and lower leg that results from compression of any of the 5 nerve roots that contribute to the sciatic nerves
What is the aetiology of sciatica?
Compression of a nerve root, most commonly L5/S1
What is the pathophysiology of intervertebral disc prolapse in sciatica?
- Intervertebral discs consist of concentric collagenous fibres (the annulus fibrosus) surrounding a central nucleus (the nucleus fibrosus) of degenerated collagen
- Healthy discs contain a great deal of water
- As a result of aging the discs become dehydrated and weaken - more prone to prolapse
- Prolapse of a disc occurs when there is a defect in the annulus fibrosus that allows the nucleus to herniate out
- Herniation often occurs as the result of strenuous physical activity involving the lumbar spine
- The prolapsed disc material can press (impinge) on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution as well as reduced power in a myotomal distribution
- The commonest site for this to occur in the spine is the lower lumbar spine with the L4, L5 and S1 nerve roots contributing to the sciatic nerve and pain radiating to the part of the sensory distribution of the sciatic nerve
What is the pathophysiology of other causes of sciatica?
- Root compression by other degenerative disease (bone spurs, canal stenosis, spondylolisthesis, facet arthropathy)
- Root compression of sinister causes (tumour, fractures, TB)
- Root compression outside the spine (piriformis syndrome,endometroisis, pelvic disease, peroneal compression)
- No root compression (arachnoiditis, peripheral neuropathies)
What is the presentation of sciatica?
- Frequently described as unilateral leg pain that is greater than the back pain
- Some patients may not have any back pain
- Sharp, shooting, electric pain
- Pain radiates to foot
- Numbness and paraesthesia in same distribution
- Nerve irritation signs
- Motor, sensory, or reflex changes in one nerve root
What is the management of sciatica?
- Prognosis reasonable - 50% recover from acute attack in 6 weeks, 90% within 3 months
- NSAIDs and analgesia
- Consider surgery if unremitting/recurrent symptoms
What is bony nerve root entrapment?
OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica
What is the management of bony nerve root entrapment?
Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates
What is spinal stenosis?
Narrowing of the central spinal canal, intervertebral foramen and/or lateral recess causing progressive nerve root compression
What is the aetiology of spinal stenosis?
- Mainly caused by degenerative joint disease in middle aged to elderly individuals
- With spondylosis and a combination of bulging discs, bulging ligamentum flavum and osteophytosis, the cauda equina of the lumbar spine has less space
What is the typical presentation of spinal stenosis?
- Generally patients over 60
- Claudication (pain in legs on walking)
- The claudication distance is inconsistent
- The pain is burning (rather than cramping)
- Spinal extension (standing or walking downhill) exacerbates symptoms while back flexion (sitting or walking uphill) improves symptoms
- Spine flexion creates more space for the cauda equina
- Pedal pulses are preserved
What is the management of spinal stenosis?
- Conservative management - analgesia, physiotherapy, weight loss if indicated
- If symptoms fail to resolve with conservative management and there is MRI evidence of stenosis, surgery may be performed (decompression to increase space for the cauda equina) to help alleviate symptoms
What is cauda equina syndrome?
Caused by compression of the nerve roots caudal to the level of spinal cord termination
What is the aetiology of cauda equina syndrome?
Most common cause is compression arising from large central lumbar disc herniation at the L4/L5 and L5/S1 level
What is the presentation of cauda equina syndrome?
- Classically bilateral leg pain, can be unilateral or with no leg symptoms
- Loss of motor or sensory function of bowel/bladder
- Loss of control/awareness (NOT constipation or increased urinary frequency)
- Perineal/saddle anaesthesia
- Widespread or progressive motor weakness in the legs or gait distribution
PR exam - loss of anal sphincter tone
What is the investigation for cauda equina syndrome?
Urgent MRI to determine level of prolapse
What is the management of cauda equina syndrome?
Urgent discectomy
What are the complications of cauda equina syndrome?
- Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion
- Even with prompt surgical intervention, significant number of patients have residual nerve injury with permanent bladder and bowel dysfunction
What is an osteoporotic crush fracture?
Withsevereosteoporosis,spontaneouscrushfracturesofthevertebralbodycanoccur leading to acute pain and kyphosis
What is the management of an osteoporotic crush fracture?
- Usually conservative
- Balloon vertebroplasty - results not yet fully evaluated, small risk of neurological injury
What are the complications of an osteoporotic crush fracture?
Aminorityofpatientsgoontohavechronicpainduetoalteredspinal mechanics
What is cervical spondylosis?
As with the rest of the spine, spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints
What is the presentation of cervical spondylosis?
- Slow onset stiffness and pain in the neck
- Pain can radiate to shoulders and the occiput
What is the management of cervical spondylosis?
Physiotherapy and analgesics
What are the complications of cervical spondylosis?
- Osteophytes can also impinge on the exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes
- May require decompression for severe symptoms resistant to conservative management
What is a cervical disc prolapse?
Acute and degenerative disc prolapse can also occur in the cervical spine producing neck pain and potentially nerve root compression
What is the presentation of a cervical disc prolapse?
- With nerve root compression, patients complain of shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected
- Typically, the lower nerve root is involved (i.e. C7 root for C6/7 disc, C8 root for C7/T1 disc)
- A large central prolapse can compress the cord leading to a myelopathy with upper motor neurone symptoms and signs
What investigations can be used for cervical disc prolapse?
- Clinical findings
- MRI
- The number of patients with asymptomatic disc prolapse increases with age resulting in a higher rate of false positives/incidental findings on MRI scanning - ensure clinical findings correlate with MRI findings before considering surgery
What is the management of cervical disc prolapse?
- Analgesia and physiotherapy
- Surgery may be considered in cases resistant to conservative management
What is atlanto-axial subluxation? and when can it occur?
In rheumatoid arthritis, atlanto‐axial subluxation can occur due to destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament
What is the main complication of an atlanto-axial subluxation?
Subluxation can result in cord compression which can be fatal
What is the management of atlanto-axial subluxation?
- Less severe cases (seen on flexion‐extension views) may be treated with a collar to prevent flexion
- More severe cases may require surgical fusion
What are lower cervical subluxations and when do they occur?
Lower cervical subluxations can occur due to destruction of the synovial facet joints and uncovertebral joints by RA
What is the potential complications of a lower cervical subluxation?
There is potential for cord compression (myelopathy) with upper motor neuron signs (wide based gait, weakness, increased tone, upgoing plantar response)
What is the management of a lower cervical subluxation?
- If instability does not involve/threaten neurological structures - conservative management (analgesia, physio)
- More severe cases may require stabilization/fusion
What are other causes of cervical spine instability?
Atraumatic cervical spine instability can also occur in Down’s syndrome
