Backache and Spinal Deformity Flashcards
what are some types of causes of back pain?
viscerogenic spondylogenic discogenic neurogenic psychogenic
name a serious viscerogenic cause of back pain?
abdominal aortic aneurysm
abdominal causes of back pain?
renal pancreatitis some gall bladder symptoms peptic ulcer disease uterine/ovarian colonic
presenting symptoms of a back problem?
back pain
leg pain
neurological symptoms
2 types of back pain?
mechanical
non-mechanical
3 presentations of back pain?
possible spinal pathology
nerve root pain
mechanical back pain
Qs to ask in back pain?
SOCRATES
was there as precipitating incident? (cough, injury, lifting etc)
2 types of leg pain?
referred
root pain
where does nerve root pain distribute?
dermatomal
describe referred pain?
dull
posterior thigh and buttock
rarely below the knee
ill defined sensory symptoms
root pain?
sharp shooting pain
invariably below the knee to foot and ankle
anatomical sensory/motor symptoms
is sciatica root or referred pain?
root
give a neurological symptoms of back pain?
bowel/urinary
- incontinence/loss of control or awareness
- perineal/saddle anaesthesia
- bilateral/unilateral/no leg symptoms
give another 3 neurological symptoms
parasthesia
numbness
weakness
are neurological symptoms red flag signs?
yes
what non medical things must be considered in a history?
litigation
social
age
occupation
name 4 red flags
non-mechanical pain
systemic upset
major, new neurological deficit
saddle anaesthesia +/- bladder or bowel upset
name 4 red flags
non-mechanical pain
systemic upset
major, new neurological deficit
saddle anaesthesia +/- bladder or bowel upset
give some possible spinal pathologies which can cause back pain
fracture (often Osteoporosis associated)
tumours (usually mets)
infection
inflammatory (AS)
what cancers commonly metastasise to bone?
Bad - breast Boys - bronchus (lung) Pee - prostate Through - Thyroid Kidneys - renal
what is the most common primary tumour in the spine?
myeloma
what in a history suggests a tumour?
weight loss fatigue anaemia insidious onset (no precipitating event) fairly constant pain (night pain)
what features of history would indicate an infection?
high temp
fever
recent foreign travel
pathogenesis of disc prolapse?
disc loses water in ageing > disc prone to damage by load, torsion, shear > disc fissure > prolapse, extrusion, sequestration > compression of nerve roots (depending on vertebral canal) > pain etc > loss of disc height and facet arthropathy
what is a protrusion?
where the IV disc is intact but bulges out when under pressure
what is an extrusion?
where the outer annulus fibrosis ruptures, allowing the inner nucleus pulposis to bulge out
what is a sequestration?
where the outer annulus fibrosis ruptures, allowing the nucleus pulposis to bulge through and a piece of the nucleus breaks off
how can the diameter of the vertebral canal affect pain?
large space = can accommodate disc prolapse etc and wouldn’t cause sciatica/leg pain
small space = not enough room so nerve roots get compressed by e.g prolapsed disc and will cause sciatica/leg pain etc
what physiological changes can occur in disc prolapse over time?
loss of disc height
facet arthropathy - can collapse
back pain +/- canal stenosis
what is degenerative disc disease?
loss of IV disc structure (water) in ageing
can loose height can cause stenosis
how can degenerative disc disease cause narrowing of the vertebral foramen?
facet joints made for a certain disc height so when this is lost they don’t really fit together causing the vertebral canal to narrow
most common back pain?
mechanical
how is mechanical back pain diagnosed?
by exclusion
no nerve root problem
no underlying pathological process
2 uncommon causes of mechanical pain?
spondylolysis
spondylolisthesis
what is spondylolysis?
linear crack in pas interarticularis
looks like a collar on the dog shape of vertebra
what is spondylolisthesis?
break in pas interarticularis allowing vertebra to slide
examination of back pain?
observation range of movement neurological assessment nerve root irritation distraction testing
observation features of spine?
straight spine
kyphosis/lordosis
scapula/iliac crest symmetrical
what can cause loss of lumbar lordosis?
scoliosis
ankylosing spondylitis
what can cause a bulging out on one side on forward bending?
scoliosis
what does extension of the spine show function of?
facet joints
what are the myotomes?
L1/2 = hip flexion
L3/4 = knee extension
L5 - foot dorsiflexion
S1/2 = ankle plantarflexion
what 4 things are tested on neurological examination?
myotomes
dermatomes
reflexes
nerve irritation
what 3 reflexes are tested?
knee jerk
ankle jerk
plantar reflex
how is nerve irritation tested?
straight leg test
would produce shooting pain along the dermatome
what is pain drawing?
where the patient marks on a picture where their pain in
can show whether dermatomal, non-anatomical etc
what is overt pain behaviour?
how the patient reacts in response to their pain
- guarding
- bracing
- rubbing
- grimacing
- sighing
waddell behavioural responses?
superficial/non-anatomical tenderness simulation distraction over-reaction to examination regional - sensory disturbance, giving way
what is a distraction test?
if a patient claims they cant perform a straight leg test because of pain, ask them to sit upright and they will do it fine
- shows they are exaggerating pain
important examination to determine cause for back pain?
PR exam
- altered sensation around anus or loss of anal sphincter tone can suggest cauda equina problem
are X rays useful in diagnosis of mechanical back pain?
no (in most cases)
when would an X ray be useful in mechanical back pain?
if you suspect spinal pathology
is an MRI diagnostic?
no
can confirm a previously though diagnosis or locate it but can give false positives
what specialised investigations are used in mechanical back pain?
MRI (beware) diagnostic facet injection Contrast enhanced CT provocation discography selective discography selective nerve block/ablation
what is sciatica?
any sort of buttock or leg pain not obviously coming from hip, knee or ankle
in a specific dermatomal distribution accompanied by neurological disturbance
- root leg pain
when is surgery performed in disc prolapse?
only for leg pain
not for back pain
does disc prolapse surgery improve neurology symptoms which are associated?
unpredictable
can often not regain reflexes
common presentations of disc prolapse?
episodic back pain
onset of leg pain +/- neurology
leg pain becomes dominant
myotomes and dermatomes distribution
how is disc prolapse treated?
not an emergency as 90% resolve within 18-24 months
only treated with surgery if cauda equina or consider surgery if it doesn’t settle within 3 months
how is backache managed conservatively?
short bed rest (debatable)
anti inflammatory +/- muscle relaxants
mobilisation
physiotherapy
second line treatment for backache?
education/reassurance etc physiotherapy osteopathy TENS/psychology surgery
