Common MSK problems spine (2)

Question 1

What ‘associated symptoms’ to ask abut in SOCRATES for back pain?

Answer 1

• sensory disturbance
• weakness
• urinary retention or incontinence
• fevers
• fatigue
• weight loss
• early morning stiffness

Question 2

What to look for/at during inspection of the spine?

Answer 2

Question 3

What to palpate during FEEL part of the spinal exam?

Answer 3

Question 4

How to assess cervical spine movement?

Answer 4

Question 5

How to assess lumbar and thoracic spine movement?

Answer 5

Question 6

Special tests in spinal examination

Answer 6

Question 7

What to do in terms of neuro examination in patient with back pain?

Answer 7

• Document sensation and power at each nerve root level
• PR examination (perianal sensation and anal tone)

Question 8

How to test for L2?

Answer 8

L2: hip flexion

Question 9

How to test for L3?

Answer 9

L3: knee extension

Question 10

How to test for L4?

Answer 10

L4: ankle dorsiflexion

Question 11

How to test for L5?

Answer 11

L5: big toe extension

Question 12

How to test for S1?

Answer 12

S1: Ankle plantarflexion

Question 13

Differential diagnosis of back pain

Answer 13

Question 14

Ix for traumatic low energy spinal fractures

Answer 14

Low energy osteoporotic fracture

• Plain x-ray
• Bone health: calcium, vitamin D, PTH
• DEXA scan to diagnose osteoporosis

Question 15

Ix for traumatic high energy fractures

Answer 15

High energy fracture

• Exclude other injury → X-ray or CT
• MRI → if concern about neurological injury or ligamentous injury

Question 16

Ix for inflammatory back pain

Answer 16

• FBC
• ESR, CRP
• immunoglobulins
• RF
• HLA-B27
• Imaging - x-ray

Question 17

Ix for infective back pain

Answer 17

• FBC
• ESR
• CRP
• blood cultures
• consider testing for TB
• Imaging: MRI
• Possible biopsy

Question 18

Ix for back pain of suspected cancerous origin

Answer 18

Blood tests:

• PSA
• myeloma screen

Local staging: CT/MRI

Distant staging: CT chest/abdo/pelvis

• Bone scan
• Bone biopsy
• Critical to determine primary tumour from metastasis

Question 19

What types of spinal problems need emergency specialist assessment?

Answer 19

Emergency specialist assessment

• Cauda equina syndrome
• Traumatic fracture
• Infection

Urgent specialist assessment

• Cancer
• red flag symptoms

Question 20

Drug therapy for non-specific / simple back pain

Answer 20

• regular analgesia not p.r.n
• initial treatment is paracetamol and NSAIDs e.g. ibuprofen or diclofenac
• add codeine
• consider the short term use of a muscle relaxant e.g. baclofen or diazepam

Question 21

Advice re activity levels in mechanical back pain

Answer 21

• Avoid bed rest
• Continue ADLs
• Increase their physical activities over a few days or weeks
• Stay at work or return to work as soon as possible
• Avoid mechanical stress eg. Lifting