Back Pain Flashcards
Red Flags (8)
Systemic Upset - Fever -Night sweats -Weight loss -Fatigue -Malaise New back pain in elderly (>60) Back pain in the young (<20) Pain constant, severe or worse at night Saddle anaesthesia Bladder/bowel upset History of cancer History of steroids
Myotome Reflexes (4)
L1/2
- Hipe flexion
L3/4
- Knee extension
L5
-Foot dorsiflexion
S1/2
- Ankle plantar flexion
Investigations
MRI 1st Line
- Lots of flash positives
- Disc inflammation (hamburger appearance)
Diagnostic Facet Infection
-Injection of steroids in the facet joint to test if there is improvement
Sciatica
Buttock &/or leg pain in a specific dermatomal distribution coupled with neurological disturbance of the L4,L5 or S1 nerve roots
Pain radiates down the sensory aspect of the sciatic nerve
Sciatica Aetiology
Osteoarthritis
- Osteophytes can impinge on nerve roots causing sciatica
Sciatica Treatment
Analgesia Maintaining mobility Physio Drugs for neuropathic pain - Gabapentin -Pregabalin -Amitryptiline Surgery -Surgical decompression for OA induced sciatica
Prolapsed Disc Aetiology
Nucleus pulpous may herniate through a tear in annulus fibrosis which can impinge on nerve roots
Characteristics of prolapsed disc
Pain in dermatomal distribution
Reduced power in myotomal distribution
neuralgic burning or severe tingling pain which radiates to the back of the thigh below the knee
Prolapsed Disc Common sites
L4/L5/S1 nerve roots
L3/L4 prolapse
L4/L5 prolapse
L5/S1 Prolapse
Signs of L3/l4 Prolapsed disc
L4 root entrapment
Pain down to medial ankle
Loss of quadriceps power
Reduction in knee jerk
Signs of L4/L5 prolapse
L5 root entrapment Pain down to foot dorm Loss of power to - extensor hallicus longus -tibialis anterior
Signs of L5/S1 prolpase
S1 root entrapment
Pain down to sole of foot
Reduction in plantarflexion
Prolapsed Disc Prolapse 1st line (5) 2nd Line (6)
1st Line
- Short bed rest
- Anti-inflamamtory +/- diazepam
- Early mobilisation
- Return to normal activity
- Education
2nd Line
- Physio
- Osteopath
- Chiropracter
- Psychologist
- Compliment therapy
- Surgery (only to reduce leg pain- no long term benefit)
Cauda Equina Syndrome
EMERGENCY
Damage to the caudal equine, the nerve roots arising from the terminal end of the spinal cord
Cauda Equina Syndrome Aetiology
Very large central disc prolapse which compresses all of the nerve roots of the caudal equina (L1-L5)
Cauda Equina Consequences
Affected nerve roots control defection and urination
Prolonged compression can cause permanent nerve damage
Cauda Equina Syndrome Signs
Bilateral leg pain
Saddle anaesthesia
Urinary retention
Faecal incontinence/ constipation
Cauda Equina Syndrome Investigations
PR exa,
MRI
Cauda Equina Syndrome Treatment
Treatment varies with cause
Spinal Fractures Management
Urgent Treatment
- Immobilise
- X-ray
- Deal with other injuries
Spinal Cord Injuries Aetiology (10)1
Swelling Oedema Iscaemia Thrombosis of small vessels Hypoxaemia Hypotension Stretching Compression Surgery Infection
Types of spinal cord injury and causes
Complete
- forced hyperextension
Incomplete
- Caused by vascular insult
- Brown-sequard
- Central cord injury
- Anterior cord injury
Scoliosis
Lateral deviation of the spine
Scoliosis Types (4)
Congenital
Early onset
Late onset
Secondary
Secondary scoliosis
Neuromuscular problems
Tumours
Cerebral palsy
Spina bifida
Mechanical Back Pain
Recurrent relapsing and remitting back pain with no neurological symptoms
mechanical back pain aetiology (8)
Obesity poor posture Poor lifting technique Lack of physical activity Depression Degenerative disc prolapse Facet joint OA Spondylosis
Spondylosis
Intervertebral discs lose water content with age which causes less cushioning and secondary OA due to increased facet joint pressure
Mechanical Back Pain Treatment
Analgesia
Physiotherapy
Acute Disc Tear Aetiology
heavy lifting
Acute Disc Tear Characteristics
Pain
- Worse when coughing
- Severe(periphery of disc is richly innervated so pain is severe)
Acute Disc Tear treatment
Analgesia
Physiotherapy
Spinal Stenosis
Narrowing of the spinal canal due to a bulging ligament flavour, osteophytes, bulging disc etc
Spinal Stenosis Epidemiology
Around 60 years old
Spinal Stenosis Presentation
Pain in legs when walking (claudication)
- Distance is inconsistent
- Burning pain
- less when walking uphill
- preserved pedal pulses
Spinal stenosis treatment
Conservative measures
- Weight loss
- physiotherapy
- analgesia
Surgery if conservative measures fail or MRI evidence of stenosis
Malignancy epidemiology
Older patients are at higher risk
Malignancy characteristics
Pain
- Constant
- Unremitting
- Worse at night
Malignancy investigations
Thorough history CRP, FBC, U&E's Bone biochemistry Plasma protein electrophoresis PSA in males Blood culture CXR Bone scan MRI
