Backache & Nechache

Question 1

Usual prognosis of backache?

Answer 1

Self-limiting, caused by minor aches and sprains

Question 2

Components of the back?

Answer 2

Vertebrae
Muscles
Ligaments
Nervous tissue

The non-nervous tissue together is called SPONDYLITIDES, and abnormalities occurring in these tissues are called SPONDYLITIS. Structural abnormalities can occur locally in spondylitides and sometimes may lead to spinal cord or root compression. Very rarely, abnormalities may occur in the nervous tissue.

Question 3

Where may pain occur in spinal disorders?

Answer 3

LOCALLY - people with backache tend to find it difficult to pin-point exactly where the pain is. It tends to be related to a whole region (lumbar or dorsal regions)

REFERRED - can be referred to buttock and thigh, but usually always above the knee. Pain may also be referred to shoulder and upper arm

ALONG NERVE ROOT - the nerve root emerges from the vertebrae through vertebral foramina, which have facet joints posteriorly and intervertebral discs anteriorly. Any disc bulging to facet joint pathology may either cause direct compression or inflammatory reactions in the nerve roots. The brain interprets such disturbances as pain in the spinal nerve originating from that particular root. Nerve root pain may be associated with loss of sensation or weakness - such features are called LOCALISING SIGNS

Question 4

Describe sciatica?

Answer 4

Nerve root pathology occurring in the region of L4-S3. It is characterised by pain tracking down the back of the leg, always below the knee and often to the foot. It may be exacerbated by coughing.

Question 5

Where would mid-lower cervical nerve root pathology manifest?

Answer 5

Along the arm and to the hand, depending on the specific nerve root(s), often associated with characteristic tingling

Question 6

3 types of back pain related to spondylitides?

2 types related to nervous tissue?

Answer 6

Spondylitides: Aches and sprains, mechanical pain, spondylolisthesis

Nervous: Disc prolapse, bony root entrapment

Question 7

Aetiology of back sprains?

Good lifting technique?

Answer 7

Affects almost everyone at some point - mostly assoc w awkward twisting or poor lifting causing muscle/ligament injuries.

Better technique involves holding the object closer to the body, giving less leverage and reducing spinal loads

Question 8

Management of back sprains?

Answer 8

Brief period of rest followed by gradual return to normal activities.

Anti-inflammatory drugs relieve symptoms, although simple analgesia is often sufficient

Always investigate to rule out the possibility of a more serious condition

Question 9

What is mechanical back pain?

Answer 9

ill-defined condition, but really may be considered as recurrent back sprains

Question 10

Aetiology of mechanical backache?

Answer 10

Possible causes:

SPONDYLOSIS - degeneration of intervertebral discs leading to increased loading of facet joints and secondary OA

Primary OA - facet joints likely to be pone to primary OA as they are synovial

However, there are many other causes, still to be determined, which involve the ligaments and muscles

Question 11

Clinical presentation of mechanical backache?

Answer 11

‘Localised’ backache which tends to recur, but this does not indicate deterioration.

Question 12

Management of mechanical backache?

Answer 12

There is no cure, but the judicious use of rest, physiology and medication will help through a bad episode.

Most people learn to live with it and try to prevent recurrence with help from physio, GP and orthopaedic specialists. Other practitioners such as osteopaths and chiropractors can provide some easing of condition by manipulation.

Question 13

What is spondylolisthesis?

Cause?

Answer 13

Not an uncommon finding in assoc with low back pain - it is slippage of one vertebra relative to the one below, and is usually found in the lumbar spine.

Caused by bony abnormality which interferes with the stability of facet joints and ligamentous attachments

Question 14

Aetiology of spondylolisthesis?

Answer 14

May be congenital or acquired, so can occur at any age. Adult forms are thought to be acquired, although some may be mild congenital abnormalities which have gone unnoticed. It appears to be acquired following an acute or, more likely, fatigue fracture of the PARS INTERARTICULARIS

Question 15

Clinical presentation of spondylolisthesis?

Answer 15

Low back pain, which is almost identical to mechanical back pain. Diagnosis made by XR, although severe slippage may be felt at the affected area.

Rarely causes neurological problems, even when major slippage, however in congenital (which is rare) the slippage is more likely to damage nervous tissue

Question 16

Management of spondylolisthesis?

Answer 16

A SPINAL CORSET may help relieve pain, otherwise management is similar for mechanical back pain. Most don’t require surgery unless severe pain, when fusion of the 2 affected vertebrae may be required

Question 17

What is spondylolysis?
Diagnosis?
Management?

Answer 17

A pars interarticularis fracture

Can be seen on XR

Defect can exist without causing pain - if pain present, conservative measures are usually successful. Rarely if severe pain spinal fusion may be required.

Question 18

What is a slipped disc?

Answer 18

A lay man’s term for disc content prolapse/herniation - discs do not slip (in fact disc prolapse is actually quite rare)

May occur in cervical or lumbar spine, but more commonly in lumbar

Question 19

Clinical presentation of disc prolapse?

Answer 19

Classically under 40, more commonly male, acute backache and/or legache, usually after a single lifting event or strain, but there is not necessarily a correlation between this and disc prolapse.

Characteristically legache passing down the back of the thigh to the foot (in contrast to referred backache which usually goes no further than the knee or upper calf)

Question 20

Anatomy of disc prolapse?

Answer 20

Extrusion of the nucleus pulposus material through the annulus fibrosis. If it extrudes posterolaterally it may impinge nerve root. If it extrudes directly posterior it may compress spinal cord, or more commonly the cauda equina

Question 21

Management of disc prolapse?

Answer 21

First rule out cauda equina syndrome. Rest and gentle, progressive mobilisation along with analgesics and anti-inflammatories. Bed rest only for a short period and traction only to enforce rest.

Most recover spontaneously as the disc material is absorbed by cells released from the bloodstream. If pain persists or localising signs get more severe, then surgical intervention to remove the disc may be required.

Prior to any surgery, myelography must be performed by injecting radio-opaque fluid into the CSF then taking an XR - the CSF will not be able to flow where the prolapsed disc presses on the nerve

Question 22

Clinical presentation of bony root entrapment?

Answer 22

Person of either sex, usually over forty who has a Hx of mechanical back pain. They develop new symptoms of pain radiating down the leg, usually made worse by exercise

Episodes are usually acute and recurrent. Physio is unlikely to help.

Question 23

Aetiology of bony root entrapment?

Answer 23

Commonly due to bony overgrowth around the vertebral formamina, secondary to degenerative change in the facet joints (i.e. they are osteophytes). These may be a result of primary OA or spondylosis (not disc prolapse!)

Question 24

Management of bony root entrapment?

Answer 24

Conservative unless the symptoms are severe, then surgery may be considered. Removal of the disc in such patients may make the condition worse, and removal of the bone is needed to free the trapped nerve roots. This may result in disturbance to the spinal stability and lead to need for fusion of the affected vertebrae.

Question 25

What is cervical spondylosis?

Answer 25

Degeneration of the cervical intervertebral discs leading to secondary OA changes in the adjacent facet joints (like in lumbar spine)

Question 26

Clinical presentation of cervical spondylosis?

Answer 26

Typically aged over 40 and more frequent in females. Dull neckache which is often referred to shoulders and upper arms. They may also experience tingling in the arms, which is often assumed to be entrapment of bony roots but this is not always confirmed on investigation.

Process can be progressive and bony root entrapment may occur with localising signs

Question 27

Management of cervical spondylosis?

Answer 27

If there are no localising neurological signs: analgesics, NSAIDs, use of soft collar and physio to relieve muscle spasm. Patients should be warned that attacks usually recur

If nerve root entrapment confirmed, fusion of the vertebrae and decompression of the nerve root may be necessary

Question 28

Clinical presentation of cervical disc disease?

Answer 28

Neck pain and referred pain to the shoulder and arms (as in spondylosis), but usually no history of neck trouble. Following the prolapse, the neck muscles may be in spasm and movement of the neck is severely restricted.

Question 29

Management of cervical disc disease?

Answer 29

Most people recover with rest, gentle traction and wearing a support collar. If localising signs are marked or symptoms do not regress, rarely surgery may be required