Back Pain

Question 1

SPONDYLOSIS

• intervertebral disc degeneration in which region of spine?
• spondylolysis is commonest cause of which condition in children?
• Ix?
• do asymptomatic require Tx?
• Mx?

Answer 1

• More commonly in cervical and lumbar regions - mainly L4/5.
• Spondylolisthesis
• Investigations: X-ray: LOSS.
• No
• Management: Bracings/corsets, NSAIDs + analgesia, surgery (rare).

Question 2

Spondylolisthesis

• what is it ?
• traumatic cases show what appearance on plain film?
• can be acute or chronic - if acute - what Mx, and how is it different to chronic?

Answer 2

slippage of vertebrae (forwards or backwards).

• Spotty dog appearance
• • Rest is good for acute patients if awaiting surgery bit not for chronic (like all mechanical problems – ‘use it or lose it’).

Question 3

Spina Bifida

• what is it?
• three types?
• which one is most severe type?
• how is the site identifiable in spina bifida occulta?
• incidence in population of spina bifida occulta?
• how is incidence reduced?

Answer 3

• non fusion of vertebral arches during embryonic development
• myelomeningocele, spina bifida occulta and meningocele
• myelomeningocele
• birth mark or hair patch on back over area where distal cord is affected
• 10%
• by use of folic acid during pregnancy

Question 4

Scoliosis

• what is it ?
• two types?
• which type affects young adolescent females? how does this type make scoliosis disappear?
• which type affects >1 vertebral body - does this type allow for movements to make scoliosis disappear?
• how is severe structural scoliosis managed?

Answer 4

• curvature of the spine
• structural and non-structural
• non-structural (postural scoliosis)
• by bending forwards - scoliosis disappears
• structural - no movement makes it disappear
• bilateral rod stabilisation

Question 5

Scheurmann’s Disease

• what is it?
• affects whom?
• symptoms?
• how many vertebrae must be involved for diagnosis?
• Xray changes?
• minor cases - mx?
• severe cases - mx?

Answer 5

epiphysitis of vertebral joints

• adolescents
• back pain, stiffness
• progressive kyphosis of spine
• > 3 vertebrae
• anterior wedging + epiphyseal plate disturbance
• minor = physio + analgesia
• major = bracing or surgical stabilisation

Question 6

Cauda Equina Syndrome

• where does cord finish?
• what happens in this condition?
• features?
• Ix?
• Mx?

Answer 6

• Cord finishes at L1-2.
• Sits in subarachnoid space.
• Cauda equina roots get compressed
• Sphincter disturbance leading to bladder or bowel dysfunction.
• Lower motor neuron lesion.
• Reflexes, tone and power are all reduced.
• Saddle anaesthesia, gait disturbance, sexual dysfunction.
• Investigations: MRI.
• Management: Urgent surgical decompression, <48 hours of onset. Symptom control: catheter, laxatives, analgesia.

Question 7

Spinal Cord Compression (oncological emergency)

• gold standard Ix?
• affects what % of cancer patients?
• extradural compression accounts for majority of cases - what is it due to?
• what level of vertebrae determines if it is UMN or LMN?

Mx?

Answer 7

MRI

90%

bone mets

ABOVE L1 - UMN
BELOW L1 - LMN

High dose dexamethasone and urgent referral for oncological assesssment

Question 8

Sciatica ?

what % are due to disc herniation?

• where do you get pain ?

Answer 8

• Pain caused by irritation or compression of sciatic nerve.
• 90% due to disc herniation.
• Pain in sciatic nerve below the knee.

Question 9

first line for non-specific back pain?

Answer 9

NSAIDs

Question 10

if over the age of 45 and prescribed NSAIDs - what should you give?

Answer 10

PPIs

Question 11

what is the pain ladder?

Answer 11

NSAIDS
steroids
Low dose opiates
High dose opiates

Question 12

Discitis

• what is it ?
• complications?
• most common cause?
• Dx? (gold)

Answer 12

infection in the intervertebral disc space.

sepsis or an epidural abscess.

Bacterial: Staphylococcus aureus is the most common cause

• MRI

Question 13

A 27-year-old man was admitted to hospital 6 hours previously following a fractured right tibia while playing a football match. His pain has been well controlled until 30 minutes ago, but he is now complaining of intense pain in his right lower leg. On examination he is in severe pain, worsened by passive movement of the foot. You are able to palpate the dorsalis pedis and posterior tibial pulse on the right foot. His heart rate and respiratory rate are both raised (110/min and 22/min respectively), and you notice he is sweating. Which is the definitive management for this condition?

analgesia 
clexane 1.5mg/kg 
fasciotomy 
IM Nail 
Intracompartmental pressure measurements

Answer 13

fasciotomy

Presence of a pulse does not rule out compartment syndrome

This is a typical history of compartment syndrome, for which the definitive management is fasciotomy.

Question 14

A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis?

raised ICP
spinal stenosis
lumbar vertebral crush fracture

Answer 14

spinal stenosis

Spinal stenosis

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down.

Question 15

Spinal Stenosis

• pain where?
• pain is worsened by ?
• pain improves by?
• confirm Dx?

Answer 15

Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness

which is worse on walking.

Resolves when sits down.
leaning forwards and crouching down

• MRI