case 9 - back pain

Question 1

how can a patient relieve their back pain?

Answer 1

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)

Question 2

when is it a good idea to see the doctor about your back pain?

Answer 2

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

Question 3

what are the treatments suggested for back pain?

Answer 3

stay active (group exercise classes, stretches)

manual therapy treatments

psychological support

painkillers (NSAIDs - ibuprofen, muscle relaxants)

hor or cold packs

Question 4

why is increased physical activity recommended to relieve back pain?

Answer 4

resting for long periods of time can worsen back pain

Question 5

what are group exercise classes?

Answer 5

taught exercise to improve posture and strengthen muscles

Question 6

what are manual therapy treatments?

Answer 6

manipulating the spine and massage (done by chiropractor, physiotherapist)

Question 7

what psychological support can be provided for patients with back pain?

Answer 7

cognitive behaviour therapy (CBT) for patients struggling to cope with their pain

challenge how you perceive the condition and change the way you think

Question 8

what is non-specific back pain?

Answer 8

back pain that does not have a specific cause that cannot be identified

Question 9

what are some medical conditions that cause specific back pain?

Answer 9

strain or sprain

a slipped (prolapsed) disc

sciatica

ankylosing spondylitis

spondylolisthesis

Question 10

how do we prevent back pain?

Answer 10

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)

Question 11

how is non-specific back pain treated compared to specific back pain?

Answer 11

specific back pain caused by medical conditions will have specific treatments whereas non-specific back pain will have more general, lifestyle-related treatments

Question 12

differentiate between a strain and a sprain

Answer 12

strain = pulled muscle
sprain = pulled ligament

Question 13

what is a slipped (prolapsed) disc and why can it cause back pain?

Answer 13

a disc of cartilage in the spine that becomes dislodged and compresses a spinal nerve = causing tingling, numbness and weakness

Question 14

what is sciatica and why can it cause back pain?

Answer 14

irritation of the sciatic nerve that runs from the lower back to the feet = causing tingling, numbness and pain in lower back

Question 15

what is ankylosing spondylitis and why can it cause back pain?

Answer 15

swelling of the joints in the spine = pain and stiffness usually worse in the morning (improves with movement)

Question 16

what is spondylolisthesis and why can it cause back pain?

Answer 16

a bone in the spine slipping out of position = can compress nerves and cause tingling, and numbness

Question 17

which more serious condition can back pain be a sign of?

Answer 17

a broken bone in the spine

infection

cauda equina syndrome (nerves in lower back become severely compressed)

malignancy (mutliple myeloma)

Question 18

what is cauda equina syndrome?

Answer 18

rare & sever spinal stenosis where many nerves in the lower back get compressed

Question 19

what are the specialist treatments suggested for back pain?

Answer 19

group exercise classes

psychological therapy

manual therapy

Question 20

what are the specialist treatments suggested for back pain?

Answer 20

nerve treatment (radiofrequency denervation)

spinal fusion surgery

Question 21

which treatments are not recommended for back pain?

Answer 21

acupuncture

traction

TENS/PENS

painkilling spinal injections (but useful for sciatica)

Question 22

which painkillers can be taken for back pain?

Answer 22

NSAIDs - ibuprofen, codeine (stronger)

muscle relaxants - diazepam (drowsiness)

Question 23

what is radiofrequency denervation?

Answer 23

needles are inserted into the spine and radio waves are sent through the needles to heat nerves and stop pain signal transmission

Question 24

what are the risks of radiofrequency denervation?

Answer 24

bleeding, bruising, infection, accidental nerve damage

Question 25

what is spinal fusion surgery?

Answer 25

surgery to fuse two vertebrae together to strengthen them and prevent nerve compression

Question 26

what are the risks of spinal fusion surgery?

Answer 26

partial paralysis (in legs and bowel) urinary incontinence

Question 27

what is the system of motor/somatosensory detection in the brain?

Answer 27

contralateral arrangement - the right side of the brain controls the left and vice versa

Question 28

name the five types of touch and pressure receptors

Answer 28

``` Meissener's corpuscles Ruffinian corpuscles Pacinian corpuscles Merkel's dicsc low threshold nerve ending ```

Question 29

how are touch and pressure detected in the brain?

Answer 29

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

Question 30

where does decussation take place in the dorsal column-medial lemniscus pathway?

Answer 30

at the level of the medulla oblongata

Question 31

what is the dorsal column-medial lemniscus pathway?

Answer 31

sensory pathway of the central nervous system responsible for detecting fine touch, vibration, proprioception and two-point discrimination

Question 32

describe the dorsal column-medial lemniscus pathway

Answer 32

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

Question 33

why is the dorsal column-medial lemniscus pathway called that?

Answer 33

because the first neurone travels up the dorsal column and the second neurone travels up the medial lemniscus

Question 34

what are nociceptors?

Answer 34

receptors that detect pain

Question 35

how is a stimulus converted into an action potential?

Answer 35

via the process of transduction

Question 36

where are nociceptors found?

Answer 36

embedded on the cell membranes of high threshold neurones

Question 37

what is different about nociceptors?

Answer 37

they require a higher stimulus to detect an action potential

Question 38

what are the types of stimuli?

Answer 38

mechanical, chemical or thermal

Question 39

how do mechanoreceptors work?

Answer 39

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

Question 40

how do chemoreceptors work?

Answer 40

cytokines are released at the site of inflammation and this enables an action potential to be initiated

Question 41

how do thermoreceptors work?

Answer 41

at certain thermal ranges, thermoreceptors undergo a conformational change allowing for an influx of ions so an action potential can be generated

Question 42

what sensory nerve pathway is responsible for pain sensation?

Answer 42

spinothalamic tract

Question 43

what are the two types of fibres in the spinothalamic tract?

Answer 43

fast-conducting, sparsely myelinated A-delta fibres = neo-spinothalamic tract slow-conducting, unmyelinated C fibres = paleo-spinothalamic tract

Question 44

why do A-delta fibres and C fibres differ in speed of conduction?

Answer 44

due to differences in thickness and myelination

Question 45

how do action potentials travel down the neo-spinothalamic tract?

Answer 45

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

Question 46

how do action potentials travel down the paleo-spinothalamic tract?

Answer 46

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

Question 47

why do action potentials travel down the neo-spinothalamic tract?

Answer 47

fast response via the A-delta fibres

Question 48

why do action potentials travel down the paleo-spinothalamic tract?

Answer 48

slow response via the C fibres

Question 49

what is the function of the reticular formation?

Answer 49

arousal = why dull, slow pain keeps you up at night

Question 50

why does dull, slow pain keep people up at night?

Answer 50

the reticular formation (responsible for arousal) is activated

Question 51

what is the function of the insula?

Answer 51

vasoconstriction, sweating, pulse rate (neospinothalamic tract - fast fibres)

Question 52

what is the function of the SII region?

Answer 52

visual integration (neospinothalamic tract - fast fibres)

Question 53

what is the function of the cingulate cortex?

Answer 53

aversion (paleospinothalamic tract - slow fibres)

Question 54

what is the function of the amygdala?

Answer 54

sense of fear (paleospinothalamic tract - slow fibres)

Question 55

what causes the musculoskeletal reflex upon pain sensation?

Answer 55

reflex arc circuit to the muscles of the region that are stimulated quickly to contract

Question 56

describe the journey of an action potential due to a pin prick in the right hip

Answer 56

mechanoreceptor - dorsal horn - thalamus - left somatosensory cortex (also to insula, and SII region)

Question 57

explain the mechanism of referred pain

Answer 57

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)

Question 58

can mechanical back pain present with neurological symptoms?

Answer 58

nope

Question 59

what are the two possible ways a vertebral disc can prolapse?

Answer 59

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

Question 60

what kind of vertebral disc prolapse can be seen in cauda equina syndrome?

Answer 60

central prolapse of a lumbar disc

Question 61

what symptoms are characteristic of cauda equina syndrome?

Answer 61

``` bilateral neurogenic sciatica reduced perineal sensation altered bladder function painless urinary retention loss of anal tone sensory dysfunction ```

Question 62

describe the development of the spinal cord

Answer 62

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

Question 63

what is the spinal cord like at 8 weeks into development?

Answer 63

lower spinal nerves are on par at the same level as the corresponding vertebral level

Question 64

what is the spinal cord like at 24 weeks into development?

Answer 64

the vertebral column lengthens and so do the nerve roots pushing the spinal cord upwards

Question 65

what is the spinal cord like at birth?

Answer 65

the conus medullaris (end of the spinal cord) is on par with L3 and nerve roots converge to form the cauda equina

Question 66

what is the spinal cord like in adults?

Answer 66

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

Question 67

which spinal nerves are affected in cauda equina syndrome?

Answer 67

L4/L5 or L5/S1 are the most common sites of nerve compression in the CES

Question 68

what is the most common cause of cauda equina syndrome?

Answer 68

disc herniation due to L4/L5 or L5/S1 being the vertebrae with the most load-bearing vertebrae

Question 69

what are the spinal levels L4/L5/S1 responsible for?

Answer 69

motor innervation of the anal sphincter innervation of the bladder and lower limb

Question 70

how does cauda equina affect the micturition reflex?

Answer 70

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

Question 71

describe the parasympathetic component of the micturition reflex and explain how that is affected in cauda equina syndrome

Answer 71

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

Question 72

describe the sympathetic component of the micturition reflex and explain how that is affected in cauda equina syndrome

Answer 72

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

Question 73

what are the red flags for cauda equina syndrome?

Answer 73

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)

Question 74

what are some early warning signs for cauda equina?

Answer 74

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

Question 75

what should clinical records include?

Answer 75

who is recording/date od record new drugs prescribed info given to the patient relevant clinical findings decisions made and by whom

Question 76

why is good note taking important for clinicians?

Answer 76

directly impacts patient care as good notes enable a doctor to explain your decisions to other healthcare professionals and legal professionals if required

Question 77

if CES is suspected, how quickly does a referral need to be made?

Answer 77

referral must be made ASAP to allow enough time for surgical treatment before syndrome is complete

Question 78

for a CES claim to be successful, what must the claimant prove?

Answer 78

that there has been a 'breach of duty' that has caused loss or damage