case 9 - back pain Flashcards
how can a patient relieve their back pain?
stay as active as possible
try exercises and stretches for back pain (walking, swimming, yoga, pilates)
take anti-inflammatory painkillers (i.e. ibuprofen)
use a hot or cold compression pack (short-term relief)
when is it a good idea to see the doctor about your back pain?
if there is no improvement within a few weeks
if pain interferes with daily life
if pain worsens
if you’re struggling to cope with the pain
what are the treatments suggested for back pain?
stay active (group exercise classes, stretches)
manual therapy treatments
psychological support
painkillers (NSAIDs - ibuprofen, muscle relaxants)
hor or cold packs
why is increased physical activity recommended to relieve back pain?
resting for long periods of time can worsen back pain
what are group exercise classes?
taught exercise to improve posture and strengthen muscles
what are manual therapy treatments?
manipulating the spine and massage (done by chiropractor, physiotherapist)
what psychological support can be provided for patients with back pain?
cognitive behaviour therapy (CBT) for patients struggling to cope with their pain
challenge how you perceive the condition and change the way you think
what is non-specific back pain?
back pain that does not have a specific cause that cannot be identified
what are some medical conditions that cause specific back pain?
strain or sprain
a slipped (prolapsed) disc
sciatica
ankylosing spondylitis
spondylolisthesis
how do we prevent back pain?
do regular back exercises and stretches
stay active (at least 150 mins of per week) + avoid sitting
check posture
be careful when lifting things
lose weight (follow healthy diet and exercise)
how is non-specific back pain treated compared to specific back pain?
specific back pain caused by medical conditions will have specific treatments whereas non-specific back pain will have more general, lifestyle-related treatments
differentiate between a strain and a sprain
strain = pulled muscle sprain = pulled ligament
what is a slipped (prolapsed) disc and why can it cause back pain?
a disc of cartilage in the spine that becomes dislodged and compresses a spinal nerve = causing tingling, numbness and weakness
what is sciatica and why can it cause back pain?
irritation of the sciatic nerve that runs from the lower back to the feet = causing tingling, numbness and pain in lower back
what is ankylosing spondylitis and why can it cause back pain?
swelling of the joints in the spine = pain and stiffness usually worse in the morning (improves with movement)
what is spondylolisthesis and why can it cause back pain?
a bone in the spine slipping out of position = can compress nerves and cause tingling, and numbness
which more serious condition can back pain be a sign of?
a broken bone in the spine
infection
cauda equina syndrome (nerves in lower back become severely compressed)
malignancy (mutliple myeloma)
what is cauda equina syndrome?
rare & sever spinal stenosis where many nerves in the lower back get compressed
what are the specialist treatments suggested for back pain?
group exercise classes
psychological therapy
manual therapy
what are the specialist treatments suggested for back pain?
nerve treatment (radiofrequency denervation)
spinal fusion surgery
which treatments are not recommended for back pain?
acupuncture
traction
TENS/PENS
painkilling spinal injections (but useful for sciatica)
which painkillers can be taken for back pain?
NSAIDs - ibuprofen, codeine (stronger)
muscle relaxants - diazepam (drowsiness)
what is radiofrequency denervation?
needles are inserted into the spine and radio waves are sent through the needles to heat nerves and stop pain signal transmission
what are the risks of radiofrequency denervation?
bleeding, bruising, infection, accidental nerve damage
what is spinal fusion surgery?
surgery to fuse two vertebrae together to strengthen them and prevent nerve compression
what are the risks of spinal fusion surgery?
partial paralysis (in legs and bowel)
urinary incontinence
what is the system of motor/somatosensory detection in the brain?
contralateral arrangement - the right side of the brain controls the left and vice versa
name the five types of touch and pressure receptors
Meissener's corpuscles Ruffinian corpuscles Pacinian corpuscles Merkel's dicsc low threshold nerve ending
how are touch and pressure detected in the brain?
touch and pressure receptors in the region send action potentials down the neurones that are part of the neurological tracts all the way up to the primary somatosensory cortex in the parietal lobe, via the brainstem and spinal cord
where does decussation take place in the dorsal column-medial lemniscus pathway?
at the level of the medulla oblongata
what is the dorsal column-medial lemniscus pathway?
sensory pathway of the central nervous system responsible for detecting fine touch, vibration, proprioception and two-point discrimination
describe the dorsal column-medial lemniscus pathway
the first neurones from the specific body region travel up the spinal cord via the dorsal column and synapse onto the second neurone of the medulla oblongata
the second neurone carries the action potential up the medial lemniscus to the thalamus where it synapses onto the third neurone
the third neurone then travels up from the thalamus to the primary somatosensory cortex, onto which it synapses
why is the dorsal column-medial lemniscus pathway called that?
because the first neurone travels up the dorsal column and the second neurone travels up the medial lemniscus
what are nociceptors?
receptors that detect pain
how is a stimulus converted into an action potential?
via the process of transduction
where are nociceptors found?
embedded on the cell membranes of high threshold neurones
what is different about nociceptors?
they require a higher stimulus to detect an action potential
what are the types of stimuli?
mechanical, chemical or thermal
how do mechanoreceptors work?
when a mechanical force is applied, the receptor undergoes a conformational change and this deformation enables an influx of ions so an action potential is initiated
how do chemoreceptors work?
cytokines are released at the site of inflammation and this enables an action potential to be initiated
how do thermoreceptors work?
at certain thermal ranges, thermoreceptors undergo a conformational change allowing for an influx of ions so an action potential can be generated
what sensory nerve pathway is responsible for pain sensation?
spinothalamic tract
what are the two types of fibres in the spinothalamic tract?
fast-conducting, sparsely myelinated A-delta fibres = neo-spinothalamic tract
slow-conducting, unmyelinated C fibres = paleo-spinothalamic tract
why do A-delta fibres and C fibres differ in speed of conduction?
due to differences in thickness and myelination
how do action potentials travel down the neo-spinothalamic tract?
fast response
first neurone synapses onto the second neurone of the dorsal horn which decussates and goes up the contralateral side to the thalamus
here, it then synapses onto the third neurone which carries the action potential straight up to the wrist region of the somatosensory cortex
= also connected to insula for vasoconstriction, sweating and increase in pulse rate + the SII region for visual integration
how do action potentials travel down the paleo-spinothalamic tract?
slow response
first neurone synapses onto the second neurone of the dorsal horn which decussates and goes up the contralateral side to the thalamus
here, it then synapses onto the third neurone which carries the action potential straight up to the wrist region of the somatosensory cortex
= also connected to cingulate cortex for aversion, amygdala for sense of fear and the reticular formation for for arousal
why do action potentials travel down the neo-spinothalamic tract?
fast response via the A-delta fibres
why do action potentials travel down the paleo-spinothalamic tract?
slow response via the C fibres
what is the function of the reticular formation?
arousal
= why dull, slow pain keeps you up at night
why does dull, slow pain keep people up at night?
the reticular formation (responsible for arousal) is activated
what is the function of the insula?
vasoconstriction, sweating, pulse rate (neospinothalamic tract - fast fibres)
what is the function of the SII region?
visual integration (neospinothalamic tract - fast fibres)
what is the function of the cingulate cortex?
aversion (paleospinothalamic tract - slow fibres)
what is the function of the amygdala?
sense of fear (paleospinothalamic tract - slow fibres)
what causes the musculoskeletal reflex upon pain sensation?
reflex arc circuit to the muscles of the region that are stimulated quickly to contract
describe the journey of an action potential due to a pin prick in the right hip
mechanoreceptor - dorsal horn - thalamus - left somatosensory cortex
(also to insula, and SII region)
explain the mechanism of referred pain
based on convergence theory
both visceral afferent (from heart) and somatic afferent (from skin) converge in the dorsal horn and synapse onto the same secondary neurone - so info is relayed up to the brain using same pathway
so brain thinks info from heart could be info from skin/muscles instead (receives information from one tissue thinking it is from the other)
can mechanical back pain present with neurological symptoms?
nope
what are the two possible ways a vertebral disc can prolapse?
posterolateral prolapse = coupled with narrowing spinal foramina (spinal stenosis), compresses one side’s spinal nerve root = tingling, numbness
central prolapse = spinal cord is compressed directly = bilateral effects (on both sides) as the spinal cord gives rise to the right and left spinal nerve roots
what kind of vertebral disc prolapse can be seen in cauda equina syndrome?
central prolapse of a lumbar disc
what symptoms are characteristic of cauda equina syndrome?
bilateral neurogenic sciatica reduced perineal sensation altered bladder function painless urinary retention loss of anal tone sensory dysfunction
describe the development of the spinal cord
at 8 weeks = the lower spinal nerves are directly opposite their respective vertebrae
at 24 weeks = lengthening of the vertebral column causes the spinal cord to shift upwards + lengthening of nerve roots such as S1
at birth = the caudal end of the spinal cord is opposite L3 and the nerve roots extend downwards to form the cauda equina
adult life = spinal cord tapers to an end at the first lumbar vertebral level (conus medullaris) and L1-S5 nerve roots merge to form cauda equina and exit at their respective foramina
what is the spinal cord like at 8 weeks into development?
lower spinal nerves are on par at the same level as the corresponding vertebral level
what is the spinal cord like at 24 weeks into development?
the vertebral column lengthens and so do the nerve roots pushing the spinal cord upwards
what is the spinal cord like at birth?
the conus medullaris (end of the spinal cord) is on par with L3 and nerve roots converge to form the cauda equina
what is the spinal cord like in adults?
the conus medullaris is at L1 and the spinal cord tapers to an end + the nerve roots merge into the cauda equina and exit at their respective foramina
which spinal nerves are affected in cauda equina syndrome?
L4/L5 or L5/S1 are the most common sites of nerve compression in the CES
what is the most common cause of cauda equina syndrome?
disc herniation due to L4/L5 or L5/S1 being the vertebrae with the most load-bearing vertebrae
what are the spinal levels L4/L5/S1 responsible for?
motor innervation of the anal sphincter
innervation of the bladder and lower limb
how does cauda equina affect the micturition reflex?
the micturition reflex has two components: parasympathetic and sympathetic
the parasympathetic is controlled by spinal levels S2-S4 which will cause the detrusor muscle to contract and the internal sphincter to relax = makes you pee
the sympathetic component is controlled by L1-L3 which will cause the detrusor muscle to relax and the internal sphincter to contract = stopping you from peeing
as in cauda equina, L4/L5 or L5/S1 are compressed, the parasympathetic component is inhibited so it cannot make you pee and as the sympathetic component is still intact = it stops you peeing even more
describe the parasympathetic component of the micturition reflex and explain how that is affected in cauda equina syndrome
the parasympathetic component of the micturition is controlled from S2-S4
they cause the detrusor muscle to contract and the internal sphincter to relax = making you pee
in cauda equina = disc prolapse compresses L4/L5/S1 and so function below these spinal levels is impaired so action that ‘makes you pee’ cannot occur = loss of urge to urinate
describe the sympathetic component of the micturition reflex and explain how that is affected in cauda equina syndrome
the sympathetic component of the micturition is controlled from L1-L3
they cause the detrusor muscle to relax and the internal sphincter to contract = stopping you pee
in cauda equina = disc prolapse compresses L4/L5/S1 and so function below these spinal levels is impaired but action that stops you peeing is controlled from L1-L3 so action is intact
what are the red flags for cauda equina syndrome?
bilateral sciatica
bilateral lower limb numbness/weakness
pain that radiates below the knees bilaterally
impaired sensation of urinary flow (urinary retention with overflow urinary incontinence)
saddle paraesthesia (loss of sensation in the perianal/genital areas)
erectile dysfunction
bladder/bowel disturbance (loss of sensation, difficulty passing urine)
what are some early warning signs for cauda equina?
no knowing whether bladder is full/empty
altered sensation when you use toilet paper
increasing difficulty when you try to urinate/control urination
pins and needles in the inner thigh/genitals region
leaking urine from bladder
loss of sensation in genitals during sexual intercourse
what should clinical records include?
who is recording/date od record
new drugs prescribed
info given to the patient
relevant clinical findings
decisions made and by whom
why is good note taking important for clinicians?
directly impacts patient care as good notes enable a doctor to explain your decisions to other healthcare professionals and legal professionals if required
if CES is suspected, how quickly does a referral need to be made?
referral must be made ASAP to allow enough time for surgical treatment before syndrome is complete
for a CES claim to be successful, what must the claimant prove?
that there has been a ‘breach of duty’ that has caused loss or damage
