Back Pain, Red Flags & Spinal Deformity Flashcards
Back pain basics
Defined as chronic if >3 months
Neck – cervical pain/neck pain
Middle back – thoracic back pain
Lower back – lumbar back pain (Most Common)
Tailbone - coccydynia
Back pain aetiology
1) Causes intrinsic to spine
a. Spinal MSK system
b. Neurological system (local)
c. Haematopoietic system
2) Causes extrinsic to spine
a. Extrinsic MSK system
b. Neighboring viscera
c. Neurological system (not local)
Back pain differentials
Degenerative - Non-specific muscular sprain, disc disease, spinal stenosis
Vascular – aortic dissection (writhing in pain), spinal SAH
Neoplasm- severe unrelenting pain, nocturnal pain, unrelieved by bed rest
Infection – risk factors, fever, spinal tenderness (*more severe at rest)
Inflammatory – ankylosing spondylitis, RA etc. (*morning stiffness)
Trauma – nontraumatic pathological fracture, risk factors
Metabolic disorder: crystal deposition diseases: gout, pseudogout, hydroxyapatite, or calcium pyrophosphate dihydrate crystal deposition diseases
Neighbouring viscera – mediastinal or retroperitoneal disease aortic aneurysm, pancreatic/LN/urological disease
Taking pain history
*ask for referred/radiated pain
Back pain Red Flags
Neurological deficit
History of cancer
Systemic features – fever, chills, night sweats, weight loss
IV drug use
Immunosuppression
Trauma
Osteoporosis
Thoracic back pain
Pain at rest and at night
Age>50 yrs or <16 yrs
What to do if red flag seen?
Neurological + MSK examination
Immobilisation if neoplasm, inflammation, infection suspected
Involve spine surgical services
Lower Back Examination
Look Feel Move:
Look – deformity, curvature
Feel – spine, paraspinal musculature, SIJ
Move – flex, extend & lateral bend spine & hip
Tests – SLR, FABER (for hip joint pain)
Neurological exam:
Power, Sensation, Tone, Reflexes (L2-5, S1)
Vascular exam
Neck pain differentials
Degeneration : cervical spondylosis, cervical radiculopathy, cervical myelopathy
Trauma: fracture, subluxation, sprain (including whiplash)
Infection: discitis, osteomyelitis, epidural abscess
Neoplasm: primary bone tumour, metastasis
Inflammation: rheumatoid arthritis, psoriatic arthritis
Vascular: Sub-arachnoid haemorrhage
Metabolic disorder: crystal deposition diseases: gout, pseudogout, hydroxyapatite, or calcium
pyrophosphate dihydrate crystal deposition diseases
Viscera - carotid dissection etc.
Red flags for neck pain
Same as back pain
+ Headache, fever, neck pain & stiffness may be due to meningitis or SAH
What to do under red flag emergency - fracture? and when to suspect?
Suspect non-traumatic fractures in patients with osteoporosis, elderly patients and patients on long term steroids.
Immobilise;
Assess upper limb & lower limb neurology, perineal sensation;
Assess further if UMN signs detected
Intervention:
XR or CT of spine region (CT preferred), Urgent MRI if has neurological deficit
What is cauda equina syndrome, how does it present and what are the causes?
= Dysfunction of multiple lumbar & sacral nerve roots
*Presentations include urinary retention, urinary or faecal incontinence, saddle anaesthesia
Cause:
1. Compressive
cauda equina compression from large central herniated lumbar disc prolapse (Most Common)
tumour, etc.
- Non-compressive
polyradiculopathy, post RT, vascular, AS etc.
What to do under red flag emergency - cauda equina syndrome?
Assess lower limb neurology, perineal sensation, anal tone and squeeze, bladder scan. Assess further if UMN signs detected
Intervention: Urgent MRI lumbar spine (including lower T spine), rest of spine if negative
What is acute foot drop and what causes it?
= Weakness of ankle dorsiflexion
The most common cause of foot drop is peroneal nerve injury. Wide differentials incl peripheral neuropathy, UMN lesions etc
What to do under red flag emergency - acute foot drop?
Assess: LL neurological exam. Check TP (inversion) – spared in Common Peroneal N lesion. Both DF & PF lost in “Flail foot”. L5 radiculopathy is painful.
Intervention: MRI Lumber spine to investigate L5 radiculopathy. EMG/NCS helpful >3weeks duration.
How does acute cord compression present?
Rapid onset spinal pain
Severe weakness / numbness of extremities
+/- sphincter disturbance
What to do under red flag emergency - acute cord compression?
Assess: A/B/C’s, temperature, neurological deficit esp level (C5-8, T1 = can be checked through upper limb; most thoracic ones can only be checked by sensation)
Intervention:
consider spinal immobilisation if suspected infection or cancer of spine
IVF if hypotensive
Dexamathasone for malignant spinal cord compression
Urgent MRI
How does spinal osteomyelitis/epidural abscess usually present?
Focal back pain and low-grade fevers (although these may be absent in some patients, especially immunocompromised)
H/O recent spinal surgery or epidural catheter placement
H/O recent systemic infection
What to do under red flag emergency - Spinal osteomyelitis +/- epidural abscess?
Assess:
A/B/C’s, temperature, neurological deficit, bloods
Intervention:
Consider spinal immobilisation, IVF if hypotensive, urgent MRI
Management:
Pathogen identification + culture & sensitivity
Decompression especially if deficit
Stabilisation if associated with instability/deformity
Dorsal SEA – laminectomy and drainage
Ventral SEA with discitis/osteomyelitis – drainage and stabilisation
What is scoliosis?
Spinal deformity with sideways or coronal curve (over 10 degrees). Also has associated vertebral rotation
What are patterns of scoliosis? How are they classified?
Patient may present with visible spinal deformity, pain, sideways listing, prominent rib hump, asymmetry of shoulders
Classified on basis of age:
Congenital
Juvenile (<10 yrs)
Adoloscent Idiopathic Scoliosis (MC) (10-18 yrs) –> usually associated with smth else if there is pain
Adult (adult onset)
Causes of scoliosis
idiopathic, congenital, neuromuscular disease, spinal pathology, unequal leg length, degeneration, connective tissue disease, spinal tumour, spinal pain etc
What are assessments/tests of scoliosis?
Assessment:
Detailed history, MSK spine exam and UL + LL neurological examination
Test : forward bending to look for rib hump (Adam’s test)
Refer to Spinal Deformity service –> Whole spine XR – AP & Lateral
May need MRI esp if atypical features or neurological exam abnormal
What are potential treatments of scoliosis?
Management:
Based on skeletal maturity, severity of deformity and progression of deformity
Options:
Observation
Bracing - for milder growing patients
Operation
What is kyphosis?
Spinal deformity with excessive convex curvature of the spine, commonly involving the thoracic spine
This is a sagittal deformity - seen upon inspecting patient from the side. Unlike scoliosis, which is a coronal deformity (seen upon inspecting patient from the back)
Thoracic spine is naturally kyphosed. Kyphosis means hyper-kyphosis – excessive kyphosis
Cause, assessment, management for kyphosis
Causes:
Scheuermanns disease, osteoporosis with wedge fractures
Asessment:
Similar to scoliosis
Management:
Majority are managed conservatively. Operative treatment for severe kyphosis
Describe spondylolisthesis
Anterior subluxation of one vertebra on another. Most Common L5/S1.
Another sagittal spinal deformity
Aetiology of spondylolisthesis
Type 1: dysplastic – congenital. Spina bifida occulta
Type 2: isthmic – defect in pars, seen at L5S1
Type 3: degenerative, seen at L4L5
Type 4: traumatic – injuries other than pars fracture
Type 5: pathologic – bone disease
How to assess severity of spondylolisthess?
Meyerding grading
Spondylolisthesis % = listhesis/AP dimention of VB above %
Grade I less than 25%
Grade II 25 - 50%
Grade III 50 – 75%
Grade IV 75 – 100%
Spondyloptosis >100%
Management for spondylolisthesis
Management:
Isthmic
Significant leg symptoms : Decompression with fusion preferred
Degenerative
Significant leg symptoms : Grade I & II with no instability on standing X-rays – Decompression only. Adverse features seen – Decompression with fusion.
For both fusion could be instrumented or non-instrumented. Postero-lateral or inter-body
What is cervical radiculopathy and how does it present?
= Dysfunction of cervical nerve root
Pain radiating from neck down into the arm; Numbness and/or weakness in the upper extremity
Causes for cervical radiculopathy + differentials from the presented symptoms
Causes:
Cervical disc prolapse
Vertebral osteophytes
Other compressive lesions like tumours
Differential diagnosis:
Shoulder joint disease, peripheral nerve compression, cervical facet joint syndrome. Referred pain - angina
Types of cervical radiculopathy
- C5 from C4/5 disc. Rare. Pain radiates to shoulder. Biceps reflex
- C6 from C5/6 disc. 20%. Pain radiates to thumb, lateral forearm. Brachioradialis reflex
- C7 from C6/7 disc. 70%. Pain radiates to fingers 2&3. Triceps reflex
- C8 fom C7T1 disc. 10%. Pain radiates to fingers 4&5. Finger reflex
Investigations + Management of cervical radiculopathy
Investigation:
MRI, CT myelogram ( if MRI contraindicated)
Management:
1. Conservative : analgesics & physiotherapy. 90% improve
2. Surgery: for arm pain refractory to conservative management, progressive neurological deficit. Options:
anterior cervical discectomy & fusion (ACDF)
anterior cervical discectomy & disc replacement (ACDR)
posterior cervical foraminotomy
What is cervical myelopathy and what are the presentations?
= Dysfunction of cervical spinal cord
History of slow progressive symptoms;
Clumsiness of hands and feet, mild gait disturbance, paraesthesia of upper and lower extremities;
Later symptoms of loss of coordination, changes in gait and stiffness, change in bowel or bladder function
What are the causes of cervical myelopathy and how is the disease classified?
Causes:
1. Disc osteophyte complex
2. Ligamentous hypertrophy
3. Degenerative spondylolisthesis
4. Other compressive lesions – tumours, pannus, canal stenosis
Classification
Ranawat
I – Pain, no deficit
II – subjective numbness/weakness, hyper-reflexia
III – objective weakness, IIIA is ambulant, IIIB is non-ambulant
Nurick
Japanese Orthopaedic Association score
Upper limb motor
Lower limb motor
Sensory symptoms
Bladder symptoms
Differentials, investigations and management of cervical myelopathy
Differential diagnosis:
subacute combined degeneration of the spinal cord (SACD), MND, MS
Investigation:
MRI, CT myelogram ( if MR contraindicated)
Management:
1. Surgery:
anterior vs posterior approaches to decompressing the spinal cord
Anterior cervical discectomy/corpectomy & fusion
Cervical laminectomy +/- instrumented fusion, Cervical laminoplasty
- Conservative:
suitable only for patients with mild symptoms (mJOA<12)
What kind of structural degeneration can happen with degenerative disc disease?
- Disc – disc desiccation, annular tears, disc bulge, disc prolapse, disc fibrosis and resorption
- Facet joint – hypertrophy, effusions and laxity
- Ligamentum flavum hypertrophy
What is lumber disc herniation?
When internal nucleus of the disc starts protruding and putting pressure on outer ring of the disc
What can lumbar disc herniation cause and what is the management?
Can cause:
1. Lumbar radiculopathy – “Dysfunction of lumbar nerve root” : Pain radiating into the leg; numbness and/or weakness in the nerve root distribution. Pain is constant, worse with WB, Valsalva & SLR
- Cauda equina syndrome – “Dysfunction of multiple lumbar & sacral nerve roots” : typical features include urinary retention, urinary or faecal incontinence, saddle anaesthesia. Lumbar radiculopathy features are also seen in most patients
Management:
Lumbar radiculopathy is managed conservatively initially. Most improve. Surgery – lumbar discectomy
What are associated pathologies in lumber stenosis and what are the types of the disease?
Facet & ligament hypertrophy, additional spondylolisthesis in some
- Central stenosis – compression of all the nerve roots passing through
- Lateral recess stenosis – compression of the transiting nerve root
- Foraminal stenosis – compression of the exiting nerve root
How does lumbar stenosis present and what are some other differentials for the presentation?
Stenosis tends to present with claudicant leg pain worse with walking/prolonged standing and relieved upon flexion of spine. Can also present with radiculopathy
Differentials:
Vascular claudication, hip OA, facetogenic pain, spinal tumour, SIJ OA
Investigation & Management for lumbar stenosis
Investigation:
MRI, CT +/- myelogram if MRI contraindicated
Management:
1. Conservative: 3/5 stable, 1/5 improve, 1/5 worse
2. Surgical options
Lumbar laminectomy – for central stenosis
Lumbar laminectomy with fusion – option for central stenosis and slip>grade II
Lumbar laminotomy (decompression) – for isolated lateral recess stenosis
Direct / Indirect foraminal decompression via I/B cage – for isolated foraminal stenosis
Limitation of extension via interspinous distraction device – MIS option for central stenosis in frail patients
