Back Pain And Spinal Disorders Flashcards
1
Q
What are the negative effects of back pain?
A
- financial (eg. Missing work)
- insomnia
- psychological (eg. Emotional stress for patient and partner, limitations in fulfilling family tasks etc.)
2
Q
What defines chronic back pain and the differentials of it?
A
- 3+ months
- most are ‘wear and tear’/non-specific
- differentials: medical/surgical emergencies, life-threatening cancers, treatable conditions
3
Q
What are the possible causes of back pain?
A
- mechanical: non-specific low back pain (NSLBP)
- referred (not from a pathology of the back)
- systemic: infection, malignancy, inflammatory
4
Q
Describe the features of ‘mechanical’ back pain
A
- onset at any age, rate varies
- worsens with movement/prolonged standing and improves with rest
- early morning stiffness <30mins
- causes: lumbar strain/sprain, degenerative discs/facet joints, disc prolapse, spinal stenosis, compression fractures
5
Q
Describe how the symptoms of mechanical back pain differ with cause
A
- lumbar strain/sprain (most common): muscle spasms settle within 24-48hrs
- degenerative disc disease (‘spondylosis’): asymptomatic for many, pain increases with flexion, sitting and sneezing - increasing pressure or squeezing disc
- degenerative facet joint disease: pain more localised and increases with extension
6
Q
What features would you see on imaging for degenerative spinal disease?
A
- decreased joint space
- worn down disc
- osteophytes around disc space
7
Q
How would you manage non-specific LBP?
A
- review diagnosis
- reassurance
- education, promote self-management (stay active)
- exercise programme and physio
- analgesics (avoid opiates)
- acupuncture
NO injections, traction, lumbar supports
8
Q
Describe the pain pathophysiology of a prolapsed disc
A
- when a disc prolapses the softer middle part of the disc bulges through the fibrous outer ring and presses on the nerve as it leaves the spinal cord
- compression of posterior nerve results in a widespread pain
- compression laterally results in dermatomal pain
9
Q
Describe the features of disc prolapse
A
- can be acute
- pain worsened on cough
- associated with leg pain (dermatome), sciatica, radiculopathy
- straight leg raising test positive
- reduced reflexes
- most resolve within 12 weeks
- minority need investigations and surgery (helps sciatica not back pain)
10
Q
Describe features of cauda equina syndrome
A
- occurs at L1/2
- neuropathic symptoms: bilateral sciatica, saddle anaesthesia
- bladder and bowel dysfunction with reduced anal tone (ask about urinary retention/incontinence)
- usually caused by a large prolapsed disc
- requires an urgent neurosurgical review
11
Q
Describe the features of spinal stenosis
A
- anatomical narrowing of spinal canal (congenital/degenerative)
- presents with claudication in legs/calves that is worse when walking
- investigations = x-ray/MRI if uncertain about diagnosis/management
- surgery high risk
12
Q
Describe the features of spondylolisthesis
A
- slip of one vertebra on the one below
- due to pars interarticularis defect (asymptomatic at most)
- pain can radiate to posterior thigh and increase with extension
- rarely needs surgery
13
Q
Describe the features of compression fracture
A
- typically elderly patient, osteoporosis
- sudden onset, severe
- pain radiates in ‘belt’ around area affected
- most pain settles in 3 months, chronic mechanical and kyphosis (more anterior compression than posterior)
- x-ray and DEXA scan required
- treatment: conservative (analgesia), calcitonin, vertebroplasty (cement), kyphoblasty (balloon)
14
Q
What can you see on imaging of a vertebral compression fracture?
A
- disc space is maintained
- bone collapses around the disc
15
Q
What conditions can cause referred pain in the back?
A
- aortic aneurysm (CVS features (increased BP and HR), collapse, pulsating abdo mass)
- acute pancreatitis (epigastric pain, relief leaning forwards)
- peptic ulcer disease (epigastric pain, worse after meals, vomit, blood/malaena)
- acute pylonephritis/renal colic (UTI/stones history, radiation, haematuria)
- endometriosis/gynae pathology
16
Q
What are the clinical signs of infective discitis?
A
- high index of suspicion needed
- fever
- weight loss
- constant back pain (worse at night)
- immunosuppressed, diabetes, IV drug use history
17
Q
What investigations and management is needed for infective discitis?
A
- bloods: FBC, ESR, CRP, blood cultures (most common = S.aureus)
- imaging: x-ray (look for vertebral destruction), MRI
- radiology-guided aspiration
- management: IV antibiotics +/- surgical debridement
- look for source
18
Q
What can imaging show for infective discitis?
A
- no disc space between vertebrae
- disc and bone irregularity
- healing leads to callus bone formation and limited functionality after
19
Q
What are the features of back pain related to malignancy?
A
- history of malignancy: lung, prostate, thyroid, kidney, breast (LP Thomas knows best)
- > 50 years
- constant pain, worse at night
- systemic symptoms, primary tumour signs and symptoms
- X-ray, MRI, bone scan
- look for primary tumour
20
Q
Describe the features of inflammatory back pain?
A
- younger onset <45y
- early morning stiffness >30mins
- may wake up during the night with buttock pain
- may have family history
21
Q
What are the red flag symptoms with back pain?
A
- new onset <16 or >50y
- following significant trauma
- previous malignancy
- systemic (fevers/rigors, malaise, weight loss)
- previous steroid use
- IV drug abuse, HIV or immunocompromised
- recent significant infection
- urinary retention
- non-mechanical pain (worse at rest)
- thoracic spine pain
22
Q
What are the red flag signs with back pain?
A
- saddle anaesthesia
- reduced anal tone
- hip or knee weakness
- generalised neurological deficit
- progressive spinal deformity
