Back pain Flashcards
What should a history regarding back pain include specifically?
- Age: older patients more likely to have disc disease and malignancy more common
- Timescale: trauma? how long?
- Leg pain: bilateral or unilateral
- Neurology: numbness/weakness/tingling? change in bowel/bladder habits?
- Screening: weight loss, systemic symptoms?
- Any previous surgical intervention/injection or falls
What does a stooped posture with flexion of the knee suggest?
- Sciatica
What does a frail elderly woman with stooped posture likely have?
- Osteoporotic fractures in vertebra (vertebral wedge fractures)
- (excessive kyphosis)
What are the main symptoms of mechanical back pain and clinical findings on examination?
- Worse on movement
- Mainly back pain (can radiate down leg but not true radiculopathy)
- Straight leg raise: negative
- Peripheral nerve examination: negative
What is the treatment for mechanical back pain?
- Conservative: analgesia (NSAIDs), physio (avoid bed rest)
- note: usually self-limiting, if persists then screen
What is a prolapsed intervertebral disc and where does it usually occur in the back?
- a disc prolapse occurs when part of the nucleus pulposus herniates through the annulus fibrosus and presses on a spinal nerve root
- note: usually occurs at L4-L5 or L5-S1 level
What are the symptoms of a prolapsed intervertebral disc (most likely causing sciatica)?
- sciatica (pain radiating down leg)
- may be numbness/tingling/weakness of the foot
- often uncomfortable to sit
- passive straight leg raise will: +ve
What are the symptoms of cauda equina syndrome (urgent MRI required)?
- altered bladder/anal function (urinary retention or incontinence)
- perineal pain/paraesthesia (saddle anaesthesia)
- bilateral leg pain/paraesthesia/weakness
Why does cauda equina syndrome affect bladder/anal function, and cause perineal paraesthesia?
- due to compression of the cauda equine which supplies motor function to the bowel and bladder sphincters, and sensation to the perineum
What is the main investigation for diagnosis of prolapsed intervertebral disc?
- MRI
Cauda equina MRI image…
What is the management for a prolapsed intervertebral disc?
- Conservative: physio, analgesia (NSAIDs)
- (note: usually self-limiting)
- Surgical: lumbar nerve root injection (can provide diagnosis and treatment for nerve root compression)
- (note: surgical discectomy only for cauda equina or progressively worsening neurological deficit)
What is spondylolisthesis, where does it usually occur, and what is the aetiology?
- Spondylolisthesis = one vertebral body slipping on another (usually occurs at the L5-S1 level)
- Aetiology: commonly fast bowlers in cricket, gymnasts
Spondylolisthesis and the grades 1-4…
What are the clinical features of spondylolisthesis?
- Most common cause of persistent back pain in children
- Clinical examination: spinal tenderness, hyperextension painful, radiculopathy (sciatica) can occur
What investigations should be done for suspected spondylolisthesis?
- X-ray: shows classic ‘collar on Scottie dog’ appearance (lateral x-ray view will show the degree and angle of slippage)
- CT scan: clearly demonstrates the lesion
- note: MRI if radiculopathy
‘Collar on Scottie dog’ appearance on x-ray in spondylolisthesis…
What is the management for spondylolisthesis?
- Conservative: physio, analgesia, and activity modification (usually self-limiting)
- Surgical: fusion and bone graft (only if persistent pain, radiculopathy, and significant deformity)
What is spinal stenosis?
- Spinal stenosis = degenerative changes narrowing the spinal canal and causing compression of the nerve roots
What are the risk factors for spinal stenosis?
- Men over 50yrs
- Heavy manual labourers
What are the clinical symptoms of spinal stenosis?
- pain when walking, reffered pain to the buttock, calves, and feet
- pain worse on extension of spine, and is better with flexion of spine (flexion opens up spinal canal)
- ‘Shoppping cart sign’: patients able to walk further when leaning on shopping trolley (spine is in flexion)
What are the investigations that should be done for suspected spinal stenosis?
- X-ray: will show degenerative changes
- MRI: shows degree of stenosis and nerve root involvement
What is the treatment for spinal stenosis?
- Conservative: weight loss, physio, activity modification, analgesia (NSAIDs)
- Surgical: surgical decompression if severe
What is discitis / vertebral osteomyelitis?
- Discitis = infection of the disc space
- Vertebral osteomyelitis = infection of a vertebral body
What are the risk factors for discitis / vertebral osteomyelitis?
- IV drug users, immunocompromised patients, diabetes
- Post disc surgery
- Recent hx of sepsis or UTI
What is Pott disease?
- Tuberculosis (TB) of the spine
What are the clinical features of discitis / vertebral osteomyelitis?
- Systemically unwell (pyrexia), and severe unrelenting back pain
- Clinical examination: swelling, tenderness, reduced movement, possible abnormal neurology
What investigations should be done for suspected discitis / vertebral osteomyelitis?
- Bloods: WCC, ESR, CRP all elevated
- X-ray: narrowed disc space (discitis), bony destruction (osteomyelitis)
- MRI: can detect a spinal epidural abscess (SEA)
- Biopsy (CT guided): for culture
Spinal epidural abscess (SEA)…
- SEA = inflammation with pus inside the epidural space
TB of the spine (Pott disease) MRI…
What is the treatment for discitis / vertebral osteomyelitis?
- Conservative: IV antibiotics for 6 weeks, follow-up MRI at 6 weeks
- Surgical: any abscess should be drained, stabilisation if significant deformity
What is the prognosis for discitis / vertebral osteomyelitis?
- Can be life-threatening
- Children: usually have good prognosis
What is scoliosis?
- Scoliosis = a lateral deviation and rotational abnormality of the spine
What are the 4 types of scoliosis and their pathology?
- Congenital: abnormal development of the spine
- Adolescent idiopathic scoliosis
- Neuromuscular: abnormal muscle forces acting on the spine (eg. cerebral palsy)
- Secondary: curve develops secondary to another process (eg. leg-length discrepancy)
What are the clinical features of scoliosis?
- usually just cosmetic (pain-free)
- curve more visible on forward flexion of spine
- note: severe deformity reduces chest expansion and can be life-threatening
What are the investigations for suspected scoliosis?
- Standing X-ray: assess degree of the curve and monitor the progress of the curve
- MRI: only to exclude other differentials
What is the treatment for scoliosis?
- Conservative: bracing if mild
- Surgical: surgical stabilisation, fusion, correction if severe
Scoliosis x-ray…
- X-ray shows thoracolumbar curve
Describe pharmacological interventions the GP should consider to manage a patient with chronic back pain.
- Use of NSAIDs
- Combine NSAIDs with proton-pump inhibitor (PPI) such as omeprazole
- If NSAID not sufficient for pain then consider an opiod (dihydrocodeine)
- Anti-depressant such as amitriptyline
In chronic low back pain, the patient may progress through three phases, give examples of the typical features that may be seen in each phase
- Phase 1 (up to 2 months): belief that pain is controllable, anxiety
- Phase 2 (2 to 6 months): varying between increased and decreased activity, depression may occur
- Phase 3 (6 to 24 months): reduced activity, side effects of pain medication may occur, belief that pain is uncontrollable, depression is common
