Back Pain Flashcards
How is touch communicated to the brain?
Dorsal-column medial meniscus system
Decussate in the medulla
Third neurone begins at the thalamus
How is pain communicated to the pain?
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
What would the route for a pin prick be?
Mechanoreceptor
Dorsal Horn in spinal cord where decussation takes place
Thalamus
What could be causing lower back pain?
Vertebra
Spinal cord
Nerve roots
Lumbar muscles
Referred pain:
Aorta
Kidneys
Pancreas
What is radiculopathy?
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).
What is cauda equina syndrome?
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.
What is mechanical back pain?
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.
What is radiculopathy?
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)
If the spinal body is damaged, what happens?
Multiple symptoms in multiple spinal roots
What causes radiculopathy?
Nucleus pulpous herniates posteriorly and laterally
‘Slipped disc’
Affects spinal root
What is sciatica?
Describes radiculopahty of the scatic nerve
Shooting pain down the back of one leg
What causes cauda equina?
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
What does Paul have?
Cauda Equina Syndrome
What are the most common sites of nerve compression in CES?
L4/L5
L5/S1
What are symptoms of CES?
Bilateral symptoms Bladder retention Bilateral leg weakness Change in bladder function Reduced perineurial function (thighs, anus) Sexual dysfunction Anal tension
What are the next steps with cauda equina?
Urgent MRI
Discussion with neurosurgeon
Need operating on within 24 hours of symptom onset
Why did Paul have back pain for years and then a more sudden onset?
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
Why does Paul have difficulty initiating micturition?
Compression is at L4/L5, everything below is affected
Sympathetic that goes to the bladder is supplied by L1/L2/L3 - contracts urinary sphincter
The pelvic nerves from S1/2/3/4 region initiate urination - relaxes urinary sphincter
There is unopposed sympathetic function
What is the difference between cauda equina and radiculopathy?
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
What is the progression of urinary function in cauda equina?
Changes in urination
Urinary intention
Overflow incontinence - pressure
What are the red flag symptoms for cauda equina?
Saddle numbness
Sexual dysfunction
Urinary retention
What are the red flag symptoms for cauda equina?
Saddle numbness Sexual dysfunction Urinary retention Bilateral sciatica Neurological deficit of the legs Loss of anal tone or impaired sensation on rectal examination
What are some neurological deficits of the legs?
Major motors weakness with knee extension
Ankle eversion
Foot dorsiflexion
What are the early warning signs for Cauda Equina syndrome?
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
What are some questions you can ask to diagnose cauda equina?
When was the last time you passed urine?
Have you noticed any changes when you have been intimate?
What must you do when someone comes in with back pain?
Tell them you think its mechanical back pain
But if they experience any of these symptoms they must see an doctor
What must you do when someone comes in with back pain?
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
Why is documentation of cauda equina syndrome so important?
Affects working age people Can cause permanent incontinence Permanent leg weakness Massive medicolegal issue Payouts in the millions - devastating affects to NHS finances
Write positive and negative findings
What must a claimant show for a claim to be successful?
Show care provided fell below reasonable standard
‘breach of duty’
Show the breach has caused loss or damage
What makes up the bulk of a CSE claim?
care costs
consequential losses
e.g. ‘loss of earnings’ if they can no longer work
How many claims were notified to the MDU between Jan 2005 and Aug 2016?
150
70% successfully defended
£350,000 were spent on legal costs
£8 million in compensation paid out
Damages payments ranged from £2,250 to £670,000
Where do surgeons make the incision in CES surgery?
Right over the area where the disc has herniated
What must surgeons cut through to reach the CE?
Small area of lamina that is removed to get into canal
Ligamentum flavum must be removed to expose spina l canal
Spinal nerves are retracted
What is done after surgery?
Probe underneath the nerve sac to make sure it is free
What happens to the spinal cord during development?
Spinal cord grows significantly slower than the vertebrae
8 weeks = spinal cord and vertebrae same length
24 weeks = spinal cord only reaches S1
Neonate = spinal cord only reaches L2 - L3
Adult = spinal cord only reaches L1/L2 (spinal roots have a long cord to get where they need)
Why does CES cause difficulty in initiating micturition?
L1-L3 are the sympathetic nerves to urinary bladder
- promote detrusor relaxation and internal sphincter contraction
- stops you peeing
L4/L5 and L5/S1 most common sites of nerve compression
S2-S4 are the parasympathetic nerves to urinary bladder
- promote detrusor contraction and internal sphincter relaxation
- makes you pee
What can stimulation of the cingulate cortex cause?
Aversion
What can stimulation of the insular cortex cause?
Vasoconstriction
Sweating
Increase in pulse rate
What can stimulation of the amygdala cause?
Fear
What can stimulation of the reticular formation cause?
Arousal
What three concepts relating to the brain are important in pain?
Somatrophic arrangement
Contralateral arrangement
Affective neuroscience
Give examples of some touch and pressure receptors?
Meissner's corpuscules Ruffinis end organs Merkels discs Pacinian corpuscules Low threshold nerve endings
Where do the dorsal columns decussate?
Medulla oblongata
What is the route for a touch action potential?
Body part
Medulla
Thalamus
Somatosensory cortex
What are pain receptors called?
Noiciception receptors
Embedded on the cell membranes on high threshold neurons
Found on plasma membrane
What can cause pain firing?
Chemical
Mechanical
Thermal
How can mechanoreceptors and thermoreceptors initiate an action potential?
Found on plasma membranes of free high threshold nerve endings
Undergo conformational change when force is applied
Allows ions in initiating action potential
How can chemoreceptors initiate an action potential?
In response to cytokines released at the site of inflammation
How does pain sensation travel to the brain?
Via the spinothalamic tracts
2 sub highways
Adelta fibres
C-fibres
