Back pain Flashcards
What are the 3 clinical classification of lower back pain ?
0 simple back pain / non -specific (Mechanical ? ) 95% - main type
0 Back pain - with nerve root pain - 4 % of pop
0 Serous spinal pathology - 1 % of pop
What is mechanical back pain ?
Pain originates from joints , bones or soft tissues in and around spine.
considered non -specific MSK pain - strained muscles , ligaments in back
DIAGNOSIS -
0 no specific cause found
o unilateral dull pain
o may radiate to buttocks but not beyond knee ( this more suggestive of sciatica )
o patient is systemically well
0 Typically caused by :
1. heavy
lifting
2. poor
posture
3. incorrect
bending
etc.
4. poorly
designed
seating
0 Pain linked to :
o position - better or worse in certain positions
o activity - worse with physical activity - especially in acute phase - first 3 months.
- Usually started to get better within a few weeks.
o X -rays of back not routinely done for non -s pecific back pain
people low back pain - always exclude sciatica , inflammatory features & serious spinal pathology.
1st apponitment - X - ray not offered , physiotherapy , manual therapy - for non -specific pain.
after one week - if no better - physio / manual can be offered.
- if inflammatory component - refer to rheumotology - after ESR , CRP investigation.
Categories of back pain - not clinical classifications ?
0 Degenerative
0 Mechanical
0 Infections
0 cancer
0 Inflammatory disorder - ankylosing sponlitis ?
0 Spinal epidural hematoma
Red flags - things to look out for - with lower back pain - TUNA FISH
T U N A F I S H
T - Trauma
U - unexplained weight loss - suggestive of possible cancer
N - Neurological symptoms -
o sensory loss,
o pain
o weakness in legs
o saddle anesthesia ( loss of sensation in the perineum(btw anus & vulva/scrotum, buttocks, groin area )
o bowel, bladder, sexual dysfunction
( LAST 3 - indicative of Cauda Equina - surgical emergency - ASAP MRI.
A - Age - over 50 - increased risk of cancer
F - Fever - possible infection ?
I - Infection
o Fever
o intravascular drug use
o immunocompromised -
HIV ,
immunosuppressant use
o UTI
o TB
S - Steroid use - secondary osteoporosis
H - History of cancer
particularly - prostate,
breast, lung & kidney
CANCER
SPINAL FRACTURE - STRUCTURAL DEFORMITY
GAIT DISTURBANCE
o tripping over -
L5 damage due
to weakness of
extensor hallicus
longus - bizarre
gait pattern.
o If they limp -
look at hip and
rule out hip
issue
o Ataxia - group
of disorders -
disturbance in
balance , co-
ordination &
speech - upper
neurone ?
- Systemically unwell
Treatment of non specific MSK pain ?
Increase mobility - important not to be immobile ( will make it worse )
- apply heat or cold
- massage
- physical therapy
- Chiropractor
Medication -
NSAIDS
o e.g ibuprofen or Naproxen - first
line - lowest dose possible
* offer gastroprotection with NSAID use.
NSAID contraindiacted , ineffective - not tolerated
o codeine with/or without paracetamol .
( take into account risk of opiod dependence , side effect - constipation )
0 Opiods not use for chronic pain.
PARACETAMOL IS NOT GOOD ENOUGH ALONE.
0 Muscle spasm present - consider short course of benzodiazepine - e.g diazepam - 5 days etc.
(Muscle relaxants e.g Cyclobenzapine
Tizanidine) -NOT MENTIONED IN NICE GUIDELINES - OSMOSIS
Usually resolved within 2 -3 weeks
( if not may have a specific cause )
Safety net - if not better within 3 -4 weeks seek follow up.
,
Causes of mechanical pain ?
Disc Herniation
- risk in
spondylosis
can happen
in healthy -
who lift heavy
object ro
trauma
- cause Lumbarsacral radioculopathy / Sciatica - due to irritation or compression of nerve root.
o shooting pain - down back below knee.- unilateral ( posterior longitudinal ligament located - posteriorly to spine -------------------> nucleus pulposus - will herniate posteriolaterally as a result compressing / irritation the nerve root on that side ( not both ) - so unilateral symptoms.
compression of nerve root below e.g :
o L3 -L4 IV DISC HERNIATION compression of L4 NR
test
squat & rise
o L4 -L5 IV DISC HERNIATION compression of L5 NR
test - heal walk
o L5 -S1 IV DISC HERNIATION compression of S1 NR
test - toe walk
positive test - indicate herniation
Straight leg raise test — patient lies down – one leg raised unitl they complain of pain( shooting pain down leg)- (btw 30 -70 degrees )positive test = radiculopathy
- should be followed up by Lumbar X ray ( shows loss of disc height - degeneration )
however should be followed by Lumbar MRI for disc herniation.
TREATMENT
ACUTE
- NSAIDS
- PHYSICAL THERAPY
- CHIROPRACTER
SEVERE
- surgery may be needed
Infection - lower back pain ?
CAUSES
- vertebral osteomyelitisSYMPTOMS
- Pain - pinpint & well localised
- Fever
- pain
- Spinal epidural abscess
SYMPTOMS
- back pain
- fever
- neurological symptoms
High index of suspection needed - as not all 3 symptoms always how up.
CAUSATIVE ORGANISMS
- S. aureus
- Streptococci
- enteric bacilli
-Pseudomonas aeruginosa - common IV drug users - mycobacterium TB - if causes osteomyeltits - called pott’s disease
SPREAD
o Haematogenous- pathogen enters blood from distant site of infection ———-infects the vetebrae
almost always leads to discitis (infected disc)
discitis —.> infection can spread from disc to epidural space causing ———> spinal epidural abscess (SEA)
SEA - can also happen on its own.
(infection in epidural space - btw veterbrae & membrane lining spinal cord
- can grow big compress adjacent nerve root or spinal cord ———-> neurological symptoms.
o directly innoculated into veterbrae during trauma/ surgery
RISK FACTORS FOR BOTH
- UTI
- immunosupression e.g chronic steroid use & HIV
- IV drug use
- endocarditis - inflammation of endocardium - inner lining of heart.
- indwelling devices e.g central venous line
- diabetes
TEST -
0 CRP - C reactive protein ( produced by liver in response to inflammation) - indicates success of treatment - rises & falls quickly
& ESR ( erythrocyte sedimentation rate - not as commonly used - CRP used instead )
0 FBC - check for leukocytosis
( CBC - complete BC - another name)
blood & urine cultures
VO - Biopsy ( find CO)
imaging
MRI better than x ray
vertebral osteomyelitis + discitis - oedema of vertebral body & destruction of intervertebral space.
abcess - fluid filled sac - appears brighter with contrast.
TREATMENT
0 antibiotics
0 surgical decompression & drainage - for abscess with neurological deficits - most be done o prevent permanent paralysis
- if now deficit - sample of abscess taken- then antibiotic tailored to result.
VO - caused TB - potts disease - treated with R I P E regimine
R - rifampin
I - Isoniazid
F- Pyrazinamide
E- ethambutol
for 2 months
then R & I for the rest of the 9 -12 months
slowly progressing infection - does not cause symptoms unitl extensive involvement e.g abcesses - extensive spread
( spinal debridement - may be needed- removal of infected tissue from spine )
Spinal epidural haemotoma
0 Bleeding in epidural space
CAUSES
- Disc herniation
- recent surgery
- Trauma
- bleeding disorder / anti- coagulation therapy
SEVERE PAIN & well localized
o can compress adjacent nerve root & spinal cord
TEST
CBC - thrombocytopenia
- PT - prothrombin time( asses for coagulation problem ) .
DIAGNOSIS
MRI - sac of blood
o can extend across multiple spinal levels - get MRI of entire spine
TREATMENT
0 Surgical decompression - as soon as possible
0 problem with coagulation —> give fresh frozen plasma
Vetebral compression fractures – lower back pain
Imaging - X - ray , Ct , MRI (MRI - can distinguish btw acute & chronic VCF )
bone density study should be look at.
TREATMENT
NSAIDS
Biphosphonates - management of osteoporosis symptoms.
Cancer - Lower back pain ?
metastatic - cancer has spread from elsewhere to epidural space , veterbral marrow
common cancers that spread to spine : o Prostate o Breast o Kidney o Lungs
SYMPTOMS
o pain o Fever o night sweats o focal neurological symptoms o unexplained weight loss o not an improvement after 4-6 weeks of conservative management.
PAIN PATTERN
o constant o worse at night o not better with rest o localized spinal tenderness
IMAGING
- MRI - to check for metastases
SUSPECT WHEN :
all of the above - others also :
o thoracic pain
What is Cauda equina syndrome ?
Compression of cauda equina - compression of lumbar & sacral nerve rots after spinal cord ends.
SYMPTOMS
0 unilateral, or bilateral asymmetric sensory loss,
0 pain or weakness in the extremities,
0 loss of reflexes.
sudden unexplained bilateral lower-extremity weakness
THESE DIFFERIATE IT FROM LUMBARSACRAL RADICULOPATHY
0 saddle anesthesia
Bilateral sciatica.
0 bowel, bladder, or sexual dysfunction.
- urinary hesitancy
- urinary retention followed by overflow urinary incontinence
diagnosis - bladder ultrasound ( see how much urine left in bladder after they relieve themselves -PVR - Post- void residual)
PVR -
normal - below 30 ml
above 100 ml - sig neurological compromise
- Fecal retention ---> followed by overfow fecal incontinence
diagnosed by digital rectal exam
- diminished sphincter tone
male - erectile dysfunction.
TREATMENT
Surgery needed within 8 hours - to prevent permanent incontinence ( bladder stretches too much - never goes back ) - MUST NOT MISS - emergency MRI needed.
- WHEN PERSON COMES IN WITH BACK PAIN - make sure they can pass urine - if patient sent home - safety net e.g if you develop urinary hesitancy , saddle etc - come back )
What is Conus Medullaris syndrome ?
Damage to Conus medullaris - most distal bulbous part of spinal cord.
similar to Cauda equina:
o saddle anesthesia
o bowel , bladder & sexual dusfunction.
Difference :
bilateral & symmetrical pattern
o urinary & fecal incontinence - early syndrome.
compression of this area - can damage corticospinal tract - upper motor neurone signs below level of lesion
- Brisk , hyperactive reflexes
- spasicity
- extensor
plantar
response /
babinski
reflex
MANAGEMENT
- emergency MRI
- surgical decompression
- if cancer is the cause - IV corticosteriods.
spinal radiation
Inflammatory causes of back pain ?
Ankylosing spondylitis
commonly affects young males
- pain in spine , sacroiliac joint , entheses
PAIN PATTERN o gradual onset o improves with exercise o morning stiffness o not improve with rest.
EXTRA - ARTICULAR MANIFESTATIONS - ( means outiside of or other than a joint. -systemic
o uvetis
o Psoriasis
o Aortic root
dilation – increase risk of aortic dissection.
CBC / FBC - might show microcytic hypochromic anaemia -
CRP , ESR - maybe elevated - indicate inflammation
o positive for HLA B27 - almost all
IMAGING
X - ray , MRI of sacral iliiac joints.
see :
erosion
sclerosis
narrowing of joint space ( if they fuse - ankylosis )
- Bamboo spine - vertebrae abnormally connected together
TREATMENT
o anti-inflammatory E.G sulfasalazine
o tumor necrosis alpha inhibitors e.g. infliximab.
Possible causes of back pain - not linked to spine / vertebrae ?
AAA - abnominal aortic aneurysm
vague back , flank pain
Pulsatile abdnominal mass
- person may become hypotensve due to blood loss
DIAGNOSIS
- abdominal ultrasound.
0 retroperitoneal hemorrhage, can develop :
- people on anticoagulation therapy
- had cannulation of the femoral artery during a cardiac catheterization procedure
lead to bilateral flank hematomas, - Grey-Turner sign.
0 aortic dissection
0 pyelonephritis,
0 renal colic
0 pancreatitis
0 pelvic inflammatory disease
0 endometriosis,
0 prostatitis.
Degenerative back pain - lower back pain ?
Degenerative - age related wear and tear
o Spondylosis (
IV discs &
facets joint -
gradually
degenerate -
osteophytes (
bone lumps -
can grow ) -
compress
adjacent
nerve roots -
causing
radicular pain
/
radiculopathy
------ can also
narrow
intervetebral
foramen -
lumbar spinal
cord stenosis
edema & swelling
( radiculopathy & lumbar spine stenosis - code - R & LSS)
o Spondylolisthesis - vertebral body slips over body below it.
CAUSES
1. FACET ----->
FORWARD (
osteoarthritis
of facte joint -
anterior slip )
2.
degenerative
disc disease
DISC
DISEASE -------
------>
DORSAL
( posterior slip
)
cause R & LSS
Diagnosis
MRI - pick up slipped disc , osteophytes , degeneration of IV disc
TREATMENT
- Pain management
- physcial therapy
- Surgery
