Back pain Flashcards
1
Q
What should a history regarding back pain include specifically?
A
- 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
2
Q
What does a stooped posture with flexion of the knee suggest?
A
- Sciatica
3
Q
What does a frail elderly woman with stooped posture likely have?
A
- Osteoporotic fractures in vertebra (vertebral wedge fractures)
- (excessive kyphosis)
4
Q
What are the main symptoms of mechanical back pain and clinical findings on examination?
A
- Worse on movement
- Mainly back pain (can radiate down leg but not true radiculopathy)
- Straight leg raise: negative
- Peripheral nerve examination: negative
5
Q
What is the treatment for mechanical back pain?
A
- Conservative: analgesia (NSAIDs), physio (avoid bed rest)
- note: usually self-limiting, if persists then screen
6
Q
What is a prolapsed intervertebral disc and where does it usually occur in the back?
A
- 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
7
Q
What are the symptoms of a prolapsed intervertebral disc (most likely causing sciatica)?
A
- sciatica (pain radiating down leg)
- may be numbness/tingling/weakness of the foot
- often uncomfortable to sit
- passive straight leg raise will: +ve
8
Q
What are the symptoms of cauda equina syndrome (urgent MRI required)?
A
- altered bladder/anal function (urinary retention or incontinence)
- perineal pain/paraesthesia (saddle anaesthesia)
- bilateral leg pain/paraesthesia/weakness
9
Q
Why does cauda equina syndrome affect bladder/anal function, and cause perineal paraesthesia?
A
- due to compression of the cauda equine which supplies motor function to the bowel and bladder sphincters, and sensation to the perineum
10
Q
What is the main investigation for diagnosis of prolapsed intervertebral disc?
A
- MRI
11
Q
Cauda equina MRI image…
A
12
Q
What is the management for a prolapsed intervertebral disc?
A
- 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)
13
Q
What is spondylolisthesis, where does it usually occur, and what is the aetiology?
A
- Spondylolisthesis = one vertebral body slipping on another (usually occurs at the L5-S1 level)
- Aetiology: commonly fast bowlers in cricket, gymnasts
14
Q
Spondylolisthesis and the grades 1-4…
A
15
Q
What are the clinical features of spondylolisthesis?
A
- Most common cause of persistent back pain in children
- Clinical examination: spinal tenderness, hyperextension painful, radiculopathy (sciatica) can occur
16
Q
What investigations should be done for suspected spondylolisthesis?
A
- 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
17
Q
‘Collar on Scottie dog’ appearance on x-ray in spondylolisthesis…
A
18
Q
What is the management for spondylolisthesis?
A
- Conservative: physio, analgesia, and activity modification (usually self-limiting)
- Surgical: fusion and bone graft (only if persistent pain, radiculopathy, and significant deformity)
19
Q
What is spinal stenosis?
A
- Spinal stenosis = degenerative changes narrowing the spinal canal and causing compression of the nerve roots
20
Q
What are the risk factors for spinal stenosis?
A
- Men over 50yrs
- Heavy manual labourers
21
Q
What are the clinical symptoms of spinal stenosis?
A
- 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)
22
Q
What are the investigations that should be done for suspected spinal stenosis?
A
- X-ray: will show degenerative changes
- MRI: shows degree of stenosis and nerve root involvement
23
Q
What is the treatment for spinal stenosis?
A
- Conservative: weight loss, physio, activity modification, analgesia (NSAIDs)
- Surgical: surgical decompression if severe
24
Q
What is discitis / vertebral osteomyelitis?
A
- Discitis = infection of the disc space
- Vertebral osteomyelitis = infection of a vertebral body
25
What are the risk factors for discitis / vertebral osteomyelitis?
- IV drug users, immunocompromised patients, diabetes
- Post disc surgery
- Recent hx of sepsis or UTI
26
What is Pott disease?
- Tuberculosis (TB) of the spine
27
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
28
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
29
Spinal epidural abscess (SEA)...
- SEA = inflammation with pus inside the epidural space
30
TB of the spine (Pott disease) MRI...
31
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
32
What is the prognosis for discitis / vertebral osteomyelitis?
- Can be life-threatening
- Children: usually have good prognosis
33
What is scoliosis?
- Scoliosis = a lateral deviation and rotational abnormality of the spine
34
What are the 4 types of scoliosis and their pathology?
1. Congenital: abnormal development of the spine
2. Adolescent idiopathic scoliosis
3. Neuromuscular: abnormal muscle forces acting on the spine (eg. cerebral palsy)
4. Secondary: curve develops secondary to another process (eg. leg-length discrepancy)
35
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
36
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
37
What is the treatment for scoliosis?
- Conservative: bracing if mild
- Surgical: surgical stabilisation, fusion, correction if severe
38
Scoliosis x-ray...
- X-ray shows thoracolumbar curve
39
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
40
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
