Case 14- Lower Back Pain Flashcards
what is the most likely prognosis of someone having back pain
Back pain is very common and usually improves within a few weeks or months
in most cases, it’s not caused by anything serious - hence will get better
what is the alternative term for lower back pain and whereas may back pain be felt?
lumbago- most common type of back pain
it can be felt anywhere along the spin
Sometimes back pain is very persistent and can come back frequently
What are the ways to relieve back pain?
Stay as active as possible and try to continue daily activites- VERY important as resting makes it worse
Try exercises and stretches for back pain, also other activities like walking, swimming yoga and pilates can help
Take antiinflammatory drugslike ibuprofen- check it’s safe for you and ask a pharmacist
Use hot or cold compression packs for short term relief: a hot water bottle or frozen veg wrapped in cloth can help
Try to stay positive and optimistic- recognise your pain will get better
Since back pain usually gets better, what are the scenarios that requires you to see a doctor?
the pain does not start to improve within a few weeks
the pain stops you doing your day-to-day activities
the pain is very severe or gets worse over time
you’re worried about the pain or struggling to cope
what other health care professionals can you go to or be referred to
GP specialist
Physiotherapist: you don’t need a doctors referral to get an appointment
What are the treatments specialists may recommend if they do not believe back pain will stop with self- help method alone
- Group exercise class - taught to strengthen muscles and improve posture- lead by a qualified instructor. it also has aerobic and stretching exercises
- Manual therapy treatments like massage and spine manipulation- can be done physio, osteopath or chiropractor
- Psychological support like CBT; very useful if you’re struggling to cope with pain
- Surgery - only if it is caused by a specific medical condition
what is the term if the cause of back pain is idiopathic?
non specific back pain- this happens very often
what are the causes of back pain
Injuries such as sprain or strains- rarely anything serious
Occasionally caused by medical conditions like:
- Slipped/prolapsed disc- where IV discs impinge on near nerve
- sciatica- irritation of sciatic nerve
- Ankylosing spondylitis
- Spondyloisthesis
what are the additional symptoms if the back pain is caused by sciatica or prolapsed disc?
- Numbness
- Weakness
- Paraesthesia
Hence they need specific treatments
How do you prevent back pain (although it is difficult to do)?
- Do regular back exercises and stretches- GP or physio will tell you what to do
- Stay active- adults should do at least 150 minutes of exercise a week
- ]Avoid sitting for long periods
- Take care when lifting- used good techniques
- Check posture when sitting; using computers, TV, etc
- Ensure mattress on your bed supports you well
- Lose weight- being overweight puts more stress on your back
What other symptoms should prompt you to contact GP or NHS 111 immediately?
- Numbness or tingling around your genitals or buttocks
- Difficulty peeing
- bladder or bowel Incontinece
- chest pain
- pyrexia
- unintentional weight loss
- swelling or a deformity in your back
- it does not improve after resting or is worse at night
- it started after a serious accident, such as after a car accident
- the pain is so bad you’re having problems sleeping
- pain is made worse when sneezing, coughing or pooing
- the pain is coming from the top of your back, between your shoulders, rather than your lower back
what is most back pain known as?
Non-specific (no obvious cause) OR
Mechanical- originates from joints, bones or soft tissue around spine
what are the features of non-specific or mechanical back pain
It gets better or worse depending on position
Often worse when moving- however do not avoid moving your back (it’ll make it worse)
Can develop suddenly or gradually
Maybe result from poor lifting or posture or no apparent reason
May be caused by minor injuries such as sprains (pulled ligament) or strain (pulled muscle)
Associated with stress or being run down
Gets better within a few weeks
What are the features and symptoms of having a prolapsed disc?
Nucleus polposis herniation and impinge on nerves
Symptoms:
- Back pain and numbness
- Tingling and weakness in other parts of the body
What is ankylosing spondylitis and outline symptoms
Swelling of joints in the spine
Causes pain and stiffness that is worse in the morning and improve with movement
What is spondylolisthesis and give symptoms
Bone in the spine slipping out of position
Cause lower back pain and stiffness
Also, cause numbness and paraesthesia
what are the features and symptoms of sciatica?q
Irritation of a component of the sciatic nerve
causes pain, numbness, tingling and weakness in:
- lower back
- Buttocks
- Legs
- feet
What are the other rare serious causes of back pain
A broken bone in the spine
infection
cauda equina syndrome (where the nerves in the lower back become severely compressed)
some types of cancer, such as multiple myeloma (a type of bone marrow cancer)
what are the condiitons for recommending surgery and procedures for back pain
what are the procedures
if there is a specific medical reason and the other treatments have not helped.
Procedures are:
- Nerve treatment
- Spinal fusion surgery
what are the features of nerve treatment? when can it be used?
Radiofrequency denervation can be used if:
- you have back pain for a long time
- Severe or moderate pain
- pain is thought to originate from joints in the spine
Needle is inserted into nerves that supply the affected joints and radio waves are sent through needles to stop the nerves sending pain signals (by heating it)
it is done under local anaesthetic and you can go home on the same day
what are the potential complications of radiofrequency denerevation
- Bleeding
- bruising
- infection
- accidental nerve damage
when can spinal fusion surgery be used and explain what it entails
recommended if there is significant damage to vertebrae bones
Can be used to fuse 2 vertebrae together and strengthen them; this stopes impingement of local nerves
what are the potential complications of spinal fusion surgery and give the probability of it occuring
Could cause permanent damage to some nerves in the back
Hence leading to partial paralysis in legs and bowel/ urinary incontinence
it occurs in 1 in 200 procedures
what are the types of treatment not recommended for back pain according to NICE
Belts, corsets, foot orthotics and shoes with “rocker” soles
Traction – the use of weights, ropes and pulleys to apply force to tissues around the spine
Acupuncture
Therapeutic ultrasound – directed at back
Transcutaneous electrical nerve stimulation (TENS) – where a machine is used to deliver small electrical pulses to your back through electrodes (small sticky patches) attached to your skin
Percutaneous electrical nerve stimulation (PENS) – where electrical pulses are passed along needles inserted near the nerves in the back
Interferential therapy (IFT) – where a device is used to pass an electrical current through your back to try to accelerate healing
Painkilling spinal injections (although these can help if you have sciatica
One of the treatments for back pain is taking NSAIDS, but what other painkillers can you take if NSAIDS are not suitable for you
Codeine may help- use only a few days as it can lead to addiction
Don’t use paracetamol on it’s own. can use together with codeine
Muscle relaxants can be prescribed if you have back spasms
- E.g diazepam
What are the side effects of muscle relaxants od diazepam and what precautions should you take
- Drwosy
- dizzy
- blurred vision
Do not drive, cycle or operate machinery if you have these S/E
why should wrap a ice pack in towel before applying to pain area
also what other method can you use for hot or cold packs
prevent cold burns
You can alternate between using hot and cold packs
what exercises can help you stay positive
10 stress busters
Breathing exercises for stress
what should always be used alongside manual therapy?
what new technique may help but hasn’t been recommended by NICE yet
Other measures like exercise
New technique- Alexander Technique
what are the features of CBT and what should you offer people who have been in pain fro a long time
it can help by changing how you think about your condition
This is because how you think about your pain can make it worse
Offer a combination of CBT, group exercises, exercises, relaxation - specialist treatment programme
what are the back stretches that can help with back pain
Kneeling stretch exercise- warm up
Back extension exercise
Knees to the chest exercise- stretches the back into bent flexed position to stretch ligament and muscles.
Knee rotation- all about movement into lower spine
Superman exercise- tone up the muscles to keep spine stable
Bridging exercises
what is cauda equina syndrome and what are the causes?
this is a medical emergency - There is a compression of spina cord in the dura at the cauda equina
Causes:
- Commonly- prolapsed disc (posteriorly)
- Other less common: infection and tumour
Can be quite difficult to diagnose in it’s earliest stages because back pain very common and CES is very rare
Why is it important NOT TO MISS a diagnosis of Cauda equina syndrome?
what should you do if you suspect it
if its’s untreated, there would be permanent damage ot the spinal nerve roots in the cauda equina.
Pt can lose permanent loss of functions like: urinary and fecal incontinence.
Pt can sue for clinical negligence as they will not be able to function properly ( claims are large)
If you suspect it, REFER immediately (24hrs) to a neurosurgeon for decompression surgery
why can CES claims be expensive?
cost of Degree of damage done from lack of care provided
Care costs and consequential losses make up the bulk of the rest.
Consequential loss could be due to loss of earnings over time especially if they have a high paying job
what is the requirement for a CES claim to be successful
Claimant has to show that care from docotr fell below standard, i.e. a breach of duty
Claimant must also show that the breach has caused loss or damage (causation)
Both claimants and defendants will instruct independent experts to investigate these two aspects of a claim
when might a CES claim result be small/negligible?
if pt has made good recovery with limited sequelae- claim will be small to reflect period of pain/suffering
If indepenedent expert evidence says the same level of injruy would occur in any event- hence it’ll be no/little compensation
- i.e if delay is only a matter of hours
- if Injury was already establised at time the patient saw the doctor
Outline the stattistics of the claims of CES faced by the MDU?
between jan 2005 and Apr 2016;
- MDU paid £ 8 mil in total compensation Most of which were under 100k.
- 12% were 500k
- MDU also paid 4.5 mil in claimant solicitor fees
State what percentage of CES claims were in Out of hour GP and explain what it means
10% of all claims related to out of hours calls or telephone call
only 1/3 was settled
This means it isa very diffuclt in assessing CES in out of hours setting
what are the red flag symptoms for CES
- Pain that radiates below the knees bilaterally (on rare occasions this can be unilateral).
- Bilateral lower limb numbness or weakness.
- Numbness either side of the buttocks and saddle area.
- Bladder and/or bowel disturbance (including difficulty passing urine, poor stream, loss of sensation).
- Diffulty innitaitng micturition, if untreated can lead to urinary overflow
- Erectile dysfunction.
- Loss of anal tone or impaired sensation on per rectal (PR) examination.
what are the MDU top tips to maximise pt safety and reduce claims
Conduct a full examination to establish the likely cause of the back pain and make a record that this has been done.
Consider any red flags.
If red flags are present, IMMEDIATELY Call the orthopaedic or neurosurgical specialist for immediate advice, or if this is not available, arrange for the patient to be admitted to hospital via the emergency department.
If no red flags are present, make a record in the notes to demonstrate you have actively considered the condition.
If, after the assessment, the patient is being managed as having simple mechanical back pain, make sure you give appropriate safety netting advice.
This should include advising the patient of the red flag symptoms and the importance of seeking urgent medical attention if these appear.
Again, try to make a record in the notes of the specific safety netting advice that has been given.
Why may patients with kidney or pancreas or aortic problems present with back pain|?
Referred pain
This means that visceral afferent fibres from organs can synpase in the same dorsal root ganglion as one from skin in the back.
The brain can confuse the signals
Explain the type or causes of back pain from the different zones in the diagram.
Explain it’s features
Zone A- Mechanical back pain:
- mechanical problem of the back: could be vertebrae or lumbar muscles
- Too much strain or maybe infection
Zone B- Spinal cord comprresed
- Commonly caused when IV disc hernate centrally and affect the spinal cord in the dura.
- Symptoms are bilateral and multiple systems of the body are affected.
Zone C- radiculopathy
- Commonly caused when IV disck herniate posteriorly and laterally and impinge on the nerve roots.
- Symptoms are unilateral and affect specific parts of the body. Affect both sensory and motor axons
how do you manage radiculopathy?
You manage it conservatively as it tends to get better on it’s own
You advice pt to rest, massge and exercise
On occasions you can do minimally invasive surgery- this is dependent of signs and sympotms and severity of it.
outline the development of the spinal cord.
In adult spinal cord stops at L2
Cauda equina is rare (0.4% of ppl with back pain)
what are it’s symptoms and what is the definite method of diagnosing cauda equina syndrome?
Bilateral symptoms:
- Loss of anal tone, sensation
- loss of bladder control; unable to pee
- Bilateral leg weakness (maybe one) - can also present with foot drop and hence you’d notice a limp whilst walking
- Reduced perinaeal sensation
- Sexual dysfunction
Only MRI can diagnose it
what is the most common site for disc herniation and how can that lead to inability to urinate
Common site- L4/L5 and L5/S1
So anything below this site is impaired. Especially PNS to urinary bladder
The S2-S4 PNS to urianry bladder via pelvic/sacral nerve is stopped and therefore you cannot relax internal urinary sphincter
However the the T12-L3 SNS to bladder is working- it promotes detrusor relaxation.
Explain how Urinary retention can lead to incontinence as CES worsens
Patient are unable to pee as baldder fulls.
Pressure builds up in bladder and overcome the constriction of the urinary sphincter
it leads to overflow bladder incontinence (very bad prognosis)
I.e the somatic, SNS and PNS are all affected
N.B. it is better to find a pt with CES who cannot pee than one with incontinence
it is important to phrase questions in a good way when asking about red flag symptoms- pt may be confused/embarrased
For each red flag symptom- outline how you would ask it to the pt
loss of feeling/pins and needles between inner thighs
Do you feel anything different when you try to pee
Do you feel anything different during sex (loss of sensation)
Loss of sensation when you move your bowels
Altered feeling when using toilet papaer to wipe yourself
Change in ability to achieve an erection or ejaculate.
TELL YOUR pts WHY you are asking these questions
Can you diagnose CES by history alone?
No you need a definite MRI that shows disc herniation in order to diagnose it
CES is normally an acute issue; give an explanation as to how it may present as acute on chronic
Firstly, back pain is very common (80%) and therefore the causes are unrelated. i.e old back pain is mechanical and new pain is CES
Secondly, the size of herniation on disc may be small at first causing radiculopathy. Then the disc gets bigger and may herniate more centrally - leading to acute on chronic CES
Explain the guidelines for documentation and why you need to document everything clearly, accurately and legibly
Document cleraly, accurately and legibly at the same time as event OR very soon afterwards
Keep records with personal information about pts, colleague etc in line with existing relevant law
Clinical records should contain:
- Relevant postiive and negative clinical findings
- decisions made and actions agree and who is making and agreeing the actions
- info given to pts (red flags)
- any drugs prescribed/ investigation/treatment
- who is making the record and when
ExplaIn the SNS mechanism for micturition
SNS efferent originate in lateral gray column of spinal chord betwenn T11- L2 or (L1-L3)
The long post–ganglionic fibres run with hypogastric nerve and synapse with alpha and beta recpetors in detrusor muscle wall, internal sphincter
Beta - causes relaxation of detrusor muscle with filling
alpha - causes tonic contraction of internal sphincter
draw the gross pathway for the spinothalamic and dorsal column leminiscal pathway
Draw out the whole pain pathway in the spinothalamic tract from relevant receptors to primary somatosensory pathway
2 types of pain
Sharp pain- carried by fast neo spinothalaic tract (A delta fibres)
- Extra Synapses at SII region then insula
dull pain- slower paleospinothalamic tract. (c-fibres)
- Places of extra synapses are: Reticular formation, sensory cortex, cingulate cortex and amygdala
There is a muscle relfex at the dorsal horn in this pathway.
In the pain pathways, what are the physiological response produced when the axon synpase at the following:
- Reticular formation
- Amygdala
- Cingulate cortex
- SII region
- Insula
Reticular formation- Arousal
Amygdala- fear
Cingulate cortex- aversion
SII region- visual integration
Insula: vasocosntriction, sweating and increase in pulse rate
what are the different types of touch receptors and draw the pathway for the dorsal column medial- leminiscus tract
Meissner’s corpuscles
Ruffini corpsucles
Pacinian corpuscles
Merkels’ discs
Free nerve endings
what is the affective neuroscience theory
Pain and sensation in some areas of the brain can trigger a physiological and motivational output
what are the classifcation of noiciceptors and describe any relevant details including where they are found and their stimuli
Mechanorecptor- found in plasma membrane of high threshold free nerve ending
- sensitive to stretch as it undergoes conformational change when force is applied to it
Themoreceptor- change to temp
Chemoreceptor: initiates action potential in response to cytokines like histamine, etc hence thats why there;’s pain in inflammation
Walk me through the surgical procedure for CES intervention
Typical microdiscectomy
A part of lamina is diseected just above the site of herniation and then you cut through ligamentum flavum
You reflect the spinal cord/nerve.
You go through the posterior longitudinal ligament.
Use appropriate tools to remove all the herniated disc material. you know that all the disc is material is removed when the spinal nerves is no longer taut
