BACK PAIN Flashcards
What is acute vs chronic low back pain?
Acute low back pain as lasting less than 3 months
Chronic low back pain as lasting 3 months or more
Epidemiology of low back pain?
Up to 60% of the adult population will have low back pain at some point in their lifetime
5-7% of adults over 45 have chronic low back pain
Prognosis of non-specific low back pain?
Self-limiting condition and usually resolved within a few weeks
People often have acute on chronic symptoms and episodes of recurrence
Possible complications of non-specific low back pain?
Impact on ADLs and function
Depression and anxiety
Time of work, reduced productivity and loss of employment
Increased risk of falls
Immobility and physical reconditioning - esp in elderly
Chronic pain
Red flags for cauda equina syndrome?
Sudden-onset bilateral Radicular leg pain or unilateral Radicular pain progressing to bilateral pain
Recent onset urinary retention or overflow urinary in continence
Faecal incontinence or recent onset loss of sensation of rectal fullness
Recent onset ED or sexual dysfunction
Perianal or perineal sensory loss
Gait disturbance
Red flags for spinal fracture?
Sudden onset severe central spinal pain relieved by lying down
History of major trauma
Structural deformity of the spine
Point tenderness over a vertebral body
Red flags for cancer causing back pain?
Age over 50
Gradual onset of symptoms or progressive pain
Severe unremitting lumbar pain, thoracic back pain, night spinal pain preventing sleep or spinal pain aggravated by straining e.g. coughing
Localised spinal tenderness
Mechanical pain
No symptomatic improvement after 4-6 weeks of conservative Tx
Unexplained weight loss
Claudication
Past Hx of cancer
Management of low back pain?
Provided you have risk stratified and they have no red flags…
Offer reassurance and self-management strategies e.g. keep active, local heat
NSAIDs if needed (with PPI if over 45)
Offer advice on exercise programmes, PT for manual therapy or psychological support
Advice requesting an occupational health assessment
Advice person to arrange review if symptoms persist or worsen after 4 weeks
Investigations for non-specific lower back pain?
MRI only if result is likely to change management e.g. if malignancy is suspected!!
What is sciatica?
Radiating leg pain caused by inflammation or compression of the Lumbosacral nerve roots forming the sciatic nerve (L4-S1)
Aka Radicular pain, lumbar radiculopathy, Lumbosacral Radicular syndrome
Prevalence of sciatica?
Lifetime prevalence is 13-40%
5-10% of people with non-specific low back pain also have sciatica
Incidence is related to age, peaking in the 5th decade before declining
Causes of sciatica?
Herniated intervertebral disc - 90%
Spondylolisthesis
Spinal stenosis
Infection (rare)
Cancer (rare)
Risk factors for sciatica?
Smoking
Obesity
Occupation - whole body vibration or strenuous physical activity e.g. frequent heavy lifting
Older age
Genetic influences
Prognosis of sciatica?
50% recover spontaneously within 6 weeks
Recurrence is common
Symptoms of sciatica?
Unilateral sharp leg pain radiating below the knee to the foot or toes
Low back pain (usually not as bad as the leg pain)
Pain is often worse when sitting and can be exacerbated by coughing/sneezing/straining
Numbness and paraesthesia in the dermatome - mostly back of thigh/calf and foot
Muscle weakness may cause diffiuclty lifting the foot, pointing toes etc (depends on specific nerve root)
Loss of ankle jerk reflex
A positive result in a straight leg raise test
What questionnaire can be used in primary care for back pain-related disability?
STarT back screening tool
Examination tests for sciatica?
Straight leg raise
Features of L3 nerve root compression?
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression?
Sensory loss anterior aspect of knee and medial malleolus
Pain from outer hip, over anterior knee and round to medial malleolus in the line
Weak knee extension and hip adduction
Difficulty with squat and rise
Reduced knee reflex
Positive femoral stretch test
Features of L5 nerve root compression?
Sensory loss dorsum of foot and lateral aspect of lower leg
Pain from midline back, around lateral gluteus and down lateral side of leg in a line
Weakness in foot and big toe dorsiflexion
Difficulty heel walking
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Pain from back down back of leg
Weakness in plantar flexion of foot
Difficulty walking on toes
Reduced ankle reflex
Positive sciatic nerve stretch test
Management of sciatica?
Self management advice e.g. stay active
Analgesia - NSAIDs +/- PPI
Offer referral to group exercise, PT and psychological therapies
Promote and facilitate return to work or normal ADLs
What is non-specific back pain?
Accounts for 85% of causes of acute back pain
When the back pain mostly involves the lumbar region, its derived from soft tissues/joints, not because of a disease or injury and is self-limiting
What is a yellow flag?
The potential psychosocial pathologies that may prolong recovery and influence the outcome - i.e. highlights pt risk of chronicity
Examples of yellow flags for back pain?
Attitudes towards the current problem - does pt feel self management will help them return to normal activities?
Beliefs - pt believing they have something serious causing their bad pain or believing activity is harmful
Compensation - is pt awaiting payment for an injury at work (ongoing litigation)
Diagnosis - inappropriate communication leading to pt misunderstanding diagnosis
Emotions - pts with concurrent depression are at higher risk of developing chronic pain
Families - over bearing or under supportive
Work - low support or dissatisfaction
Causes of all back pain?
Muscle/ligament sprain
Facet joint dysfunction
Sacroiliac joint dysfunction
Herniated disc
Spondylolisthesis
Scoliosis
Degenerative changes
Torticollis
Whiplash
Cervical spondylosis
Spinal fracture
Cauda equina
Spinal stenosis
Ankylsing spondylitis
Spinal infections
Pneumonia
Ruptured AAA
Kidney stones
Pyelonephritis
Pancreatitis
PID
Endometriosis
Nerve roots of the sciatic nerve?
L4-S3
Anatomical course of the sciatic nerve?
Derived from the Lumbosacral plexus
Leaves the pelvis and enters gluteal region via greater sciatic foramen
Emerges inferiroly to the piriformis muscle and descends in an inferolateral direction
Enters posterior thigh by passing deep to the long head of the biceps femoris
Within the posterior thigh it gives rise to the branches of the hamstring muscles and adductor Magnus
When the sciatic nerve reaches the apex of the popliteal fossa it terminates by bifurcating into the tibial ans common fibular nerves
Motor functions of sciatic nerve?
Posterior compartment of the thigh
Hamstring portion of adductor Magnus
And indirectly…
Tibial nerve - posterior calf muscles and some intrinsic foot muscles
Common fibular nerve - muscles of anterior leg, lateral leg and remaining intrinsic foot muscles
Sensory functions of the sciatic nerve?
The sciatic nerve does not have any direct cutaneous functions. It does provide indirect sensory innervation via its terminal branches:
Tibial nerve – supplies the skin of the posterolateral leg, lateral foot (sural) and the sole of the foot (medial calcaneal)
Common fibular nerve – supplies the skin of the lateral leg (deep fibular and sural) and the dorsum of the foot (superficial fibular)
What is piriformis syndrome?
Piriformis syndrome refers to compression of the sciatic nerve by the piriformis muscle. It is also known as deep gluteal syndrome.
Caused by trauma, overuse injuries, contusion to gluteal area, hypertrophy of muscle e.g. in athletes, anatomical anomaly, tumours, vascular anomalies.
Clinical features include middle-upper part of buttocks pain that radiates al down the leg, numbness, pin point tenderness on buttocks and muscle weakness. The pain can occasionally be exacerbated by internal rotation of the lower limb at the hip.
Investigations for acute back pain?
FBC
ESR and CRP
Urinalysis
PSA
Protein electrophoresis
CT or MRI if presence of red flags and imaging likely to alter management
Which spinal roots form the lumbar plexus?
L1, L2, L3, L4
What are the major branches of the lumbar plexus?
Iliohypogastric nerve
Ilioinguinal nerve
Genitofemoral nerve
Lateral cutaneous nerve
Femoral nerve
Obturator nerve
(I I Get Leftovers On Fridays)
Roots of iliohypogastric nerve?
L1
Function of iliohypogastric nerve?
Motor - internal oblique and transversus abdominis
Sensory - posterolateral gluteal skin in pubic region
Roots of ilioinguinal nerve?
L1
Function of the ilioinguinal nerve?
Motor - internal oblique and transversus abdominis
Sensory - skin on superior antero-medial thigh, root of penis and anterior scrotum, skin over mons pubis and labia majora
Roots of genitofemoral nerve?
L1 and L2
Functions of genitofemoral nerve?
motor - cremasteric muscle
Sensory - skin of anterior scrotum, over mons pubis and labia majora
Functions of lateral cutaneous nerve of the thigh?
Motor - none
Sensory - anterior and lateral thigh down to the level of the knee
Roots of the lateral cutaneous nerve of the thigh?
L2, L3
Roots of obturatory nerve?
L2, L3, L4
Functions of the obturator nerve?
Motor - muscles of medial thigh
Sensory - skin over medial thigh
Roots of femoral nerve?
L2, L3, L4
Functions of the femoral nerve?
Motor - anterior thigh muscles
Sensory - skin on anterior thigh and medial leg
What roots form the sacral plexus?
S1, S2, S3, S4
Branches of the sacral plexus?
Superior gluteal nerve
Inferior gluteal nerve
Sciatic nerve
Posterior femoral nerve
Pudendal nerve
(Some Irish Sailors Pester Polly)
Roots of superior gluteal nerve?
L4, L5, S1
Functions of superior gluteal nerve?
Motor - gluteus minmus, gluteus medius and tensor fascia lata
Sensory - none
Roots of inferior gluteal nerve?
L5, S1, S2
Functions of inferior gluteal nerve?
Motor - gluteus maximus
Sensory - none
Roots of sciatic nerve?
L4, L5, S1, S2, S3
Roots of posterior femoral cutenaour nerve?
S1, S2, S3
Function of posterior femoral cutaneous nerve?
Motor - none
Sensory - skin on posterior surface of thigh and leg + skin of perineum
Roots of pudendal nerve?
S2, S3, S4
(“S2, 3, 4 keeps the poo off the floor)
Functions of pudendal nerve?
Motor - skeletal muscles in perineum, external urethral sphincter, external anal sphincter and levator ani
Sensory - penis, clitoris and most skin of perineum
What is spinal stensois?
A narrowing of part of the spinal canal resulting in compression of the spinal cord or nerve roots
Most commonly affects the lumbar spine
Who is spinal stenosis most common in?
Pt older than 60 relating to degenerative changes in the spine
Types of spinal stenosis?
Central stenosis – narrowing of the central spinal canal
Lateral stenosis – narrowing of the nerve root canals - compresses nerve roots
Foramina stenosis – narrowing of the intervertebral foramina - compresses nerve roots
Causes of spinal stenosis?
Congenital
Degenerative changes - most common!
Herniated discs
Thickening of ligamenta flava or posterior longitudinal ligament
Spinal fractures
Spondylolisthesis
Tumours
Ligaments of the lumbar spine?
Anterior and posterior longitudinal ligaments run the length of the vertebral column and cover the vertebral bodies and intervertebral discs
Ligamentum flavum connects laminae of adjacent vertebrae
Interspinous ligament connects spinous processes of adjacent vertebrae
Supraspinous ligament connects tips of adjacent spinous processes
What is spondylolisthesis?
Anterior displacement of a vertebra out of line with the one below
Happens with age and due to stress fractures
Presentation of spinal stensois?
Gradual onset of
Intermittent neurogenic claudication - lower back pain, buttock and leg pain with leg weakness
Bending forwards improves symptoms as it expands the spinal canal
Neuropathic pain - if severe compression there may be features of cauda equina syndrome or if more mild it may cause symptoms of sciatica
Investigations for spinal stensois?
MRI
Exclude PAD e.g. ABPI and CT angiogram
Management of spinal stenosis?
Conservative - exercise, weight loss, analgesia, PT
Laminectomy
What are spondyloarthritis?
A term describing a group of clinically heterogenous inflammatory rheumatologic conditions
May be axial (ankylosing spondylitis) or peripheral (psoriatic arthritis or reactive arthritis)
How does ankylosing spondyltis present?
Young man with lower back pain and stiffness of insidious onset but for >3 months
Stiffness if worse in the morning and improves with exercise
Pain at night
Reduced forward flexion and lateral flexion
Which cancers most commonly metastasises to the spine?
Breast
Lung
Prostate
Renal
GI
Thyroid
Symptoms suggestive of spinal metastasis?
Unrelenting lumbar back pain that is progressive
Any thoracic or cervical back pain
Worse with sneezing, coughing or straining, standing, sitting or moving
Nocturnal
Associated with localised tenderness
Past or current Ca diagnosis or suspected Ca diagnosis
What are the 3 types of spinal tumours?
Extradural - within the vertebrae (most common and usually mets)
Intramedullary - within the spinal cord
Extramedullary - arise from a range of tissues (e.g. meningioma or schwannoma) within the space between the dura and the spinal cord
What is the main complications of metastatic spinal tumours?
Metastatic spinal cord compression
What are spinal haematomas and what are the different types?
Colectins of blood within the spinal canal which can compress the spinal cord and nerves
Epidural, subdural, subarachnoid and Intramedullary (i.e. within the spinal cord itself)
Types of spinal infections?
Vertebral osteomyelitis
Discitis
Spinal epidural abscess
Meningitis
Rare - spinal subdural emphysema and spinal cord abscess
What is discitis?
An infection in the intervertebral disc space
Presentation of discitis?
Back pain
Fever, rigors, sepsis
Neurological symptoms e.g. changing lower limb neurology
Causes of discitis?
Bacterial - most commonly its caused by staph aureus
Viral
TB
Aseptic
Usually from haematological spread from UTI or TRI or post-op complication from staph aeurs
Diagnosis of discitis?
MRI
CT-guided biopsy may be required to guide antimicrobial treatment
MRI findings in discitis?
Hyper intensity of the disc and inflammation surrounding it
Treatment of discitis?
6-8 weeks of IV antibiotics
What must all pt with discitis be assessed for?
Endocarditis - this is because discitis is usually due to haematogenous seeding so the seeding may have also occurred elsewhere
Complications of discitis?
Sepsis
Epidural abscess
What is a spinal epidural abscess?
A collection of pus superficial to the dura mater covering the spinal cord
It’s an emergency!!
Outline the pathophysiology of spinal epidural abscess?
Bacteria enter the spinal epidural space by contiguous spread from adjacent structures e.g. discitis, haematogenous spread from concomitant infections e.g. IVDU, or direct infection e.g. spinal surgery
More likely in immunosuppression
Most common causative micro-orgasms of spinal epidural abscess?
Staph aureus
Presentation of spinal epidural abscess?
fever
back pain
focal neurological deficits according to the segment of the cord affected.
Investigations for spinal epidural abscess?
Bloods - CRP, HIV, hep B, Hep C, coag, group & save
Blood cultures
CXR and urinanalaysis/culture
MRI whole spine
Treatment of spinal epidural abscess?
All patients will require a long-term course of antibiotics which is at first broad spectrum but maybe later refined based on culture results.
Patients with large or compressive abscesses, patients with significant or progressive neurological deficits or those who are not responding to antibiotics alone are considered for surgical evacuation of the abscess.
Presentation of osteoporotic vertebral fractures?
Asymptomatic
Acute back pain
Breathing diffiuclties
GI problems due to compression of abdominal organs
Loss of height
Kyphosis
Localised tenderness on palpation of spinous processes
What is scoliosis?
Curvature of the spine in the coronal plane
Can be postural which means it typically disappears on manoeuvres such as bending forward
What is spondylolysis?
This is a congenital weakness of stress fracture of the pars interarticularis of the neural arch of a particular vertebral body, usually L4/L5
Most common in children
What is cervical spondylosis?
Symptoms?
Degenerative disease of the neck
Very common in people over 40
Causes neck & shoulder pain or stiffness that comes and goes. Often causes headaches that start at the back of the neck
Femoral neuropathy presentation?
Groin pain
Sensory disturbances above the knee
Difficulty with knee extension and hip flexion
Loss of muscle bulk of quadriceps
Loss of patella jerk reflex
Neurological level of reflexes?
Bicep C5
Supination C6
Tricep C7
Knee L3/L4
Ankle S1
Jaw - pons
What is isthmic spondylolisthesis?
Subluxation of 1 vertebral body anterior to the adjacent inferior vertebral body caused by a defect in the pars interarticularis
Affects L5/S1 and cause foraminal stenosis
Who is isthmic spondylolisthesis most common in?
Those who do sports that involve repetitive hyperextension e.g. gymnasts, weight lifters
Presentation of isthmic spondylolisthesis?
Axial back pain
L5 radiculopathy
Neurogenic claudication caused by spinal stenosis - buttock and leg pain worse with walking
Most commonly affected disc for disc prolapse?
L5/S1
Structure of the intervertebral discs?
Concentric collagen out fibres (annulus fibrosus) surround a central nucleus of degenerated collagen (nucleus pulposus)
Why do we lose vertical height as we age?
The intervertebral discs hold a lot of water and as we age the disc dehydrates and we lose height
Pathophysiology of disc herniation?
Intervertebral discs dehydrate as we age and this gradually weakens them and makes them prone to prolapse. This often occurs as a result of strenuous physical activity involving the lumbar spine
Types of disc herniation?
Posterolateral - compresses next lower nerves - most common
Central (posterior) - may compress the spinal cord or lead to cauda equina syndrome
Lateral - nerve root compression
Stages of disc herniation?
Bulging - extension of the disc margin beyond the margins of the adjacent vertebral endplates
Protrusion - posterior longitudinal ligament remains intact but nucleus pulposus impinges annulus fibrosus
Extrusion - nuclear material emerges through annular fibres but posterior longitudinal ligament remains intact
Sequestration - the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space
Presentation of disc prolapse?
Back pain
Buttock or leg pain
Altered sensation
Motor weakness
Altered reflexes
Imaging modality of choice for disc herniation?
MRI
Management of disc herniation?
90% will resolve spontaneously
Activity modification, analgesia, PT
In severe cases then local steroids injections can be given
If it lasts >3 months, not responsive to analgesia, worsening neurological Sx etc - operation (microdiscectomy)
