Back Pain Flashcards
what components contribute to back pain
biological
psychological
social
what should be included in the Hx of back pain
onset previous episodes site and nature of pain radiation of pain neuro symptoms
red flags of back pain in history
- Non – mechanical pain; pain that does not vary with activity
- Systemic upset
- Major, new, neurological deficit
- Saddle anaesthesia (loss of feeling localised at the buttocks) +/- bladder or bowel upset
myotomes involved in - hip flexion, knee extension, foot dorsiflexion & EHL and ankle plantarflexion
Hip flexion - L1/2
Knee extension - L3/4
Foot dorsiflexion & EHL - L5
Ankle plantar flexion - S1/2
what is overt pain behaviour
Guarding Bracing Rubbing Grimacing Sighing
what is mechanical back pain
recurrent relapsing and remitting back pain with no neuro symptoms.
worse with movement; relieved by rest
what can cause mechanical back pain
obesity poor posture lack of physical activity degenerative disc prolapse facet joint OA spondylosis
what is spondylosis
disc degeneration leading to increased loading and accelerated OA of the facet joints
Tx for mechanical back pain
Analgesia
Physiotherapy
what can be done to test nerve irritation
straight leg test
what Ix is not advised in back pain
x-ray
- will see pathology related to age; red herring
main first line Ix for back pain
MRI
what is sciatica
Buttock and / or leg pain in a specific dermatomal distribution accompanied by neurological disturbance.
what is normal presentation of disc prolapse
variety of syndromes and presentations
leg pain and neurology important feature
when is surgery preformed in disc prolapse cases
for leg pain
what is common presentation of disc prolapse
Episodic back pain
Onset of leg pain +/- neurology
Leg pain becomes dominant
Myotomes and dermatomes will tell you where the disc prolapse is
what is the Tx for disc prolapse
70% settle in 3 months
90% settle in 18-24 months
consider surgery after 3 months - open discectomy
Mx of Backache
short bed rest
anti-inflmmatory +/- muscle relaxant
mobilise
normal activity
what does backache often accompany
headache and tiredness
increased diagnosis of mental disorder
why is surgery in back pain controversial
long term results (>5 years) are the same whether operated on or not
what is the typical Hx of spinal claudication
Age 50 +
M > F
Heavy duty job
Obese
symptoms spinal claudication presents with
Limited walking capacity
stoop/sit/lean forward to relieve symptoms
‘heavy’ or ‘tired’ legs
how can spinal claudication be differentiated from vascular claudication
spinal
- Relieved by flexing
- Uphill often not bad
- Cycling easy
vascular
- relieved by standing
- uphill bad
- cycling bad
what causes spinal claudication
spinal stenosis
signs/symptoms of spinal stenosis
activity related back pain
previous back surgery
leg pain when walking
stooped posture when walking
Ix for Spinal stenosis
MRI
what causes discogenic back pain classically
lifting a heavy object (eg lawnmower).
signs/symptoms of discogenic back pain
severe pain
segmental instability
worse as day goes on
worse on coughing
Tx for discogenic back pain
symptoms usually resolve 2-3 months
Analgesia
Physiotherapy
what is discogenic back pain also called
acute disc tear
what is segmental instability pain
background ache, with exacerbations and remissions
central lower back pain
how does Facet Arthropathy present
Stiff in the morning “Loosen up routine” “Restless” Difficulty sitting, driving, standing Worse with extension Better with activity Often radiates to buttocks and legs
what are the red flags for back pain
Age less than 20 or more than 50 - first back pain
Non – mechanical, constant pain
History of cancer - particularly of any known to spread to bone
History of steroids
General malaise, fever, unexplained weight loss
Structural deformity
Saddle anaesthesia / paraesthesia +/- loss of bowel or bladder control
Severe pain longer than 6 weeks
when taking an x-ray of the spine what must you ensure to image
C7/T1
what is typical of a central cord injury
Typically hyperextension injury
Arms worse than legs
what is typical of Brown-Sequard injury
Paralysis on ipsilateral side
Hypaesthesia on contralateral side
what is typical of anterior cord injury
Motor loss
Loss of pain and temperature sense
Deep touch, position and vibration preserved
when is surgery advised and when is it not is spinal cord injuries
complete cord lesion - not advised
incomplete cord lesion - controversial
how is cervical spine damage managed
reduction with traction
Posterior approach for facet dislocation
Anterior approach for retropulsed fragments
Decompression and fusion + fixation
what do thoracolumbar fractures often cause
complete paraplegia
what can be done in thoracolumbar fractures with only partial cord damage
Decompression by anterior route
Transthoracic / retroperitoneal
Mechanically unstable fracture
Stabilisation
what are sign/symptoms of cauda equina syndrome
Bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia
what can cause cauda equina
large central herniated disc or a pathological or traumatic fracture
what is Heuter-Volkmann’s law
increased pressure across an epiphyseal plate inhibits growth
what is scoliosis
lateral curvature of the spine
can be idiopathic or secondary to neuromuscular disease, tumour etc
what is Spondylolisthesis
slippage of one vertebra over another and usually occurs at the L4/L5 or L5/S1 level
