Back Pain Flashcards
what are the five categories of back pain
viscerogenic spondylogenic (originates in spinal chord and its associated structures) discogenic neurogenic psychogenic
what are abdominal causes of back pain
AAA renal colic pancreatitis peptic ulcer disease gallbladder uterine/ovarian colonic
describe root leg pain
dermatomal distribution, sharp, shooting, below knee, anatomical sensory and motor symptoms
what type of pain in sciatic
root pain
describe referred leg pain
down to back of knee- not below it, dull, gnawing, buttock, thigh, ill defined sensory symptoms
what are red flags of back pain
neurological- bowel/ urinary: incontinence, loss of control/ awareness. perineal/ saddle anaesthesia. bilateral/ unilateral/ no leg symptoms. paraesthesia, numbeness and weakness
no mechanical pain (doesnt vary with activity, worse at night
systemic upset
major, new, neurological deficit
what are 4 possible spine pathologys causing pain
fracture
tumour
infection
inflammatory conditions (e.g. AS)
what are the most common spine cancers
usually secondary
most common primary is myeloma
what cancers metastasise to bone
(bad little boys pee through kidneys)
breast, lungs, bronchus, prostate, thyroid, kidney
what are the local effects of spine infection
destruction of vertebrae, collection of pus
what condition most commonly predisposes spinal fractures
osteoporosis
what other feature might suggest cancer
weight loss, fatigue, anaemia, insidious onset of pain, night pain
what tends to cause nerve root problems
a protuding disc
what direction do discs usually protrude and what nerves do they affect
come out posterolaterally
affect traversing nerve (e.g. disc between L5 and S1 protrusion will affect nerve S1)
what can lead to a disc prolapse
impaired disc nutrition making it prone to damage by load, torsion, shear= disc fissure
what are the different types of disc prolapse
protrusion- prolapse contained by posterior ligament
extrusion- defect in annulus fribosus, usually not contained
sequestration- disc goes out into canal
what causes pain in a disc prolapse in the large vertebral canal
back pain from stretch annulus/ posterior long ligament
what causes pain in a disc prolapse when the vertebral canal in small
root compression, raised inflammatory markers,
what does loss of disc height (normal with ageing) cause
facet arthropathy (facet joints become maligned)= back pain +/- canal stenosis
what types of back pain can degenerative back pain cause
MBP- osteoarthritis, facet arthropathy
NRP- stenosis (osteophyte formation) or narrowing (loss of disc height)
what is the management for MBP
non surgical- physio
what is spondylolostheisis
when vertebrae slips forward onto bone beneath it (enabled by a fracture or defect)
what is spondylolysis
stress fracture/ defect in the pars interarticularis of vertebral arch
what do you look for in observation of the back and side in examination
deformity, asymmetry, hairy patches, neurofibromata, sometimes muscle spams
name two things that can cause loss of lumbar lordosis
AS or spasm
what will forward bending accentuate
structural deformity e.g. rib hump in scloliosis
what classifies as pathologically stiff in schobers test
less than 18cm
what problems might be exacerbated with hyperextension of spine
facet arthropathies
What are the types of nerve irritation tests
straight leg raised + variants for sciatic nerve
femoral stretch for femoral roots
what myotome for hip flexion
L1/2
what myotome for knee extension
L3/4
what myotome for foot dorsiflexion and extensor hallucis longus
L5
what myotome for ankle plantarflexion
S1/2
what does scaitic nerve irritation test
tight hamstrings
nerve irritation when you lift leg up straight with foot flexed and get a shooting pain radiating down the dermatome. drop leg until pain goes then dorsiflex foot and if pain comes back sciatic nerve irritation
how do you do a femoral stretch
extend hip, flex the knee
what is overt pain behaviour
guarding bracing rubbing grimacing sighing
what is a non anatomical pain
reflex behavioural response
what is a straight leg raise distraction test useful for
people exaggerating their problem
when should you do a rectal exam
spinal pathology or any possible suggestion of cauda equina syndrome
what are the specialised spinal investigation
MRI (76% false positive)
diagnostic facet injection
contrast enhanced CT- myelogram
provocation discography
selective nerve block/ ablation
what is a high intensity zone on MRI
white area- seen in e.g. annular tear
what will a patient think sciatica is
vague buttock or leg pain
what is sciatica
buttock and/ or leg pain in a specific dermatomal distribution accompanied by neurological disturbance
what is the surgery for a disc prolapse used to treat
leg pain not back pain
what is the common presentation of a disc prolaspe
episodic back pain
onset of leg pain +/- neurology
leg pain becomes dominant
myotomes and dermatomes
only when is a disc prolapse a surgical emergency
if there is cauda equina symptoms
most settle without surgery in 3-24 months
what is the treatment for disc prolapse
conservative treatment, consider therapy if not resolving after 3 months
what is the management for back ache
conservative treatment
- short bed rest
- anti inflammatory +/- muscle relaxant
- mobilise thereafter (fast, acitve rehab)
- physical therapies
- x rays (only if severe)
- return to normal activity
education
physio/osteopathy/chiropractic
TENS/ psychology/ pain clinic
surgery
what are BAD managements of backache
bed rest bed rest with traction narcotics > 2 weeks benzodiazepines >2 weeks steroids plaster jacket manipulation under general anaesthetic
what markers are often raised in bone disease
calcium and alkaline phophatase
what is spinal claudication
when narrowing of spinal canal causes symptoms like vascular claudication but not as severe and often helped by bending forward
when should you do an MRI for back pain
only if red flags or considering surgery
what is seen on x ray of osteoarthritis
loss loss of joint space osteophytes sclerosis subarticular cysts
what are the yellow flags for chronic back pain
low mood high levels of pain/ disability belief that activity is harmful low education level obesity problem with claim/compensation (secondary gain) job dissatisfaction light duties not available at work lot of lifting at work
