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