Back Pain Flashcards
what are the red flags of back pain?
-pain in patient 60
-constant pain, pain that is worse at night
(ie non-mechanical pain)
-systemic upset
-major, new neurological deficit
-saddle anaesthesia +/-bladder/bowel upset
-PHx of cancer
what myotomes are in control of hip flexion?
L1/2
what myotomes are in control of knee extension?
L3/4
what myotomes are in control of foot dorsiflexion?
L5
what myotomes are in control of ankle plantarflexion?
S1/2
how do you test L1/2? (hip flexion)
push on anterior aspect of thigh and ask patient to push up against your hand
how do you test L3/4? (knee extension)
when knee is flexed, push on anterior aspect of leg and ask patient to straighten their knee against your hand
how do you test for superficial/ non-anatomical tenderness?
pinch the skin
what is axial loading testing?
applying pressure on the spine by pushing on head- this should not increase pain, but if patient says it does you need to consider psychosocial factors
what is sciatica?
buttock or leg pain caused by irritation of the sciatic nerve
what is the timing of back pain due to a disc prolapse?
episodic
what pain tends to become dominant over the back pain in a disc prolapse?
leg pain
when is a prolapsed disc an emergency?
if there are cauda equina symptoms/signs
when do you consider surgery for a disc prolapse?
if pain is not resolving after 3 months
why do you not immediately consider surgery for a disc prolapse?
long term results of conservative treatments are the same
most resolve on their own
what is adjacent segment disease?
symptomatic disease of the spinal segments adjacent to a fusion operation
what is cauda equina syndroma?
pressure or swelling on the nerves of the cauda equina, untreated can lead to paralysis
what are the 2 main initial symptoms of cauda equina syndrome?
- various urinary upsets
- painless urinary retention with overflow
when taking an C-ray of the cervical spine what must you ensure the X-ray shows?
C7/T1
what does saddle sparing do to the diagnosis of complete cord injury?
no longer complete cord injury
what type of movements typically are more likely to have central cord injury?
hyperextension
what is Brown-Sequard syndrome?
damage to one side of the spinal cord causing paralysis on the ipsilateral side and hypaesthesia on the contralateral side
what is brown-sequard syndrome usually seen in?
trauma
ie fracture
what is anterior cord syndrome?
damage to the 2/3 anterior of the spinal cord causing motor loss, loss of pain and temperature but preservation of fine touch and proprioception
what is anterior cord syndrome usually seen in?
vascular supply problem
why in anterior cord syndrome are fine touch and proprioception preserved but pain and temperature are lost?
fine touch and proprioception are carried in posterior tracts
pain and temperature are carried in anterior/lateral tracts (which are damaged)
what is the benefit of a short segment fusion over a long segment fixation surgery?
in short fusion the implant doesn’t need to be removed
in long fixation the implant has to be removed after 1 year
what are the differences between spinal and vascular claudication in terms of what happens on standing?
vascular claudication is relieved by standing
spinal claudication is made worse
what are the differences between spinal and vascular claudication in terms of what happens on flexing?
spinal claudication is relieved by flexing
vacular claudication is not
what are the differences between spinal and vascular claudication in terms of what happens on walking up hill?
vascular claudication pain is worse on walking up hills
in spinal claudication pain might actually improve (due to flexed position)
what are the differences between spinal and vascular claudication in terms of cycling?
in spinal claudication cycling is easy (due to flexed position)
in vascular claudication all sport/exercise (like cycling) is difficult
what kind of pain occurs with a patient with a degenerative disc?
aching, poorly-localised, central back pain- usually lower back
(discogenic pain)
what happens to discogenic pain as the day goes on?
becomes worse
what happens to discogenic pain on activity?
becomes worse
how long does it take a patient with facet arthropathy to ‘loosen up# in the mornings?
about 20 minutes
compare discogenic pain to facet arthropathy in terms of what movement make the pain worse?
facet arthropathy is worse with extension
discogenic pain is worse with flexion
what is the surgical treatment of a prolapsed disc?
disectomy
what is the surgical treatment of a disc degeneration?
interbody fusion
what is the surgical treatment of spinal stenosis causing claudication?
root decompression and then stabilisation
what is the surgical treatment of facet arthritis?
excision of facets and fusion
what is mechanical back pain?
recurrent relapsing and remitting back pain with no neurological symptoms
(no red flag symptoms present)
what exacerbated mechanical back pain?
movement
what relieves mechanical back pain?
rest
what age are patients typically when tehy present with mechanical back pain?
20-60 years ol
what are the 8 main causes of mechanical back pain?
- obesity
- poor posture
- poor lifting technique
- lack of physical activity
- depression
- degenerative disc prolapse
- facet joint OA
- spondylosis
what is spondylosis?
where the invertebral discs lose water content with age resulting in less cushioning and increased pressure on facet joints
what can spondylosis commonly lead to?
facet joint OA (due to increased pressure)
what is the mainstay of treatment for mechanical back pain?
analgesia and physiotherapy
why should bed rest be avoided in patients with mechanical back pain?
will lead to stiffness and spasm of the back which may exacerbate disability
what minority of patients with mechanical back pain can be considered for spinal stabilisation?
-single level (ie 2 adjacent vertebrae) affected by OA or instability
AND
-patient has not improved despite physio and conservative management
what is vertebral instability?
excessive motion caused by degenerative disc
how is vertebral instability typically diagnosed?
MRI
what part of the invertebral disc is involved in an acute disc tear?
annulus fibrosis
what is the classic activity that causes an acute disc tear?
lifting a heavy object
what characteristically exacerbates the pain from an acute disc tear?
coughing
what is the mainstay of treatment for an acute disc tear?
analgesia and physiotherapy
what can happen to the nucleus polposis of an intervertebral disc after an acute disc tear?
it can herniate or prolapse through the tear
what is the treatment of OA if the facet joints causing nerve root impingement?
surgical decompression with trimming of impinging osteophytes
what is spinal stenosis?
when there is not enough space for the cauda equina so nerve roots become compressed/irritates
compare spinal claudication to vascular claudication in terms of distance at which pain starts?
vascular- distance is consistent
spinal- distance is inconsistent
compare spinal claudication to vacular claudication in terms of the type of pain?
vascular- cramping
spinal- burning
why is the pain in spinal claudication less when walking uphill?
spine flexion creates more space for the cauda equina
what is the first line treatment of spinal stenosis?
conservative treatment
with physio and weight loss
when can decompression surgery be considered for a patient with spinal stenosis?
-if symptoms fail to improve with conservative treatment
AND
-if evidence of stenosis on MRI
what is cauda equina syndrome?
a surgical emergency where a large disc prolapse compresses all the nerve roots of the cauda equina
if a patient comes in with bilateral leg symptoms/signs and any suggestion of altered bladder/bowel function, what is this condition until proven otherwise?
cauda equina syndrome
if you suspect cauda equina syndrome what are the 3 main necessary steps?
- rectal examination
- MRI
- urgent discetomy
what are the main symptoms/signs a spontaneous osteoporotic rush fracture can lead to?
- acute pain
- chronic pain (due to altered spinal mechanics)
- kyphosis
what is the managment of osteoporotic crush fractures?
conservative
what is the new operative management of osteoporotic crush fractures?
balloon vertebroplasty
what is the management for less severe cases of atlanto-axial subluxation?
treated with a collar to prevent flexion
what is the management for more severe cases of atlanto-axial subluxation?
surgical fusion
what are the 2 main conditions which are known for atraumatic cervical spine instability?
rheumatoid arthritis
down’s syndrome
What are the 4 types of low back pain that make up the diagnostic triage?
simple back pain
nerve root pain
serious spinal
cauda equina syndrome
describe the leg pain in a patient with nerve root pain?
unilateral leg pain which is greater than the back pain
also parasthesia in the same distribution
compare the ages of simple back pain and serious spinal pathology?
simple back pain: 20-55
serious spinal pathology 55
compare the timing of pain between simple back pain and serious spinal pathology?
simple- occurs during movement
serious spinal pathology- constant unremitting
