Common MSK problems_spine Flashcards
1
Q
(4) etiologies that back pain can be divided into
A
- simple backache/non-specific low back pain
- nerve root pain/radicular pain
- serious spinal pathology
- pathologies where back pain is an associated presentation
2
Q
Red flags for lower back pain
A
- age < 20 years or > 50 years
- history of previous malignancy
- night pain
- history of trauma
- systemically unwell e.g. weight loss, fever
3
Q
Simple low back pain
- demographics
- nature/ characteristics
- investigations
A
- usually lumbrosacral (may have associated buttock and thigh pain)
- pain is mechanical
- otherwise well
Investigations: do not need lumbar spine X-rays or blood tests unless there is diagnostic doubt
- low back pain affects around one-third of the UK adult population each year
- between 20 - 55 y old
4
Q
Pathophysiology of mechanical back pain
A
- Soft tissue injury → dysfunction of whole spine → muscle spasm → pain
- May have inciting event: e.g. lifting
- Younger patients with no sinister features
5
Q
Management of simple/ mechanical back pain
A
Conservative
- max 2 days bed rest
- Education: keep active, how to lift / stoop
- Physiotherapy
- Psychosocial issues re. chronic pain and disability
- Warmth: e.g. swimming in a warm pool
Medical
- Analgesia: paracetamol ± NSAIDs ± codeine
- Muscle relaxant: low-dose diazepam (short-term)
6
Q
Features of nerve root back pain
A
- Symptoms caused by prolapse of intervertebral disc
- Most common in lumbar spine (but also occur in cervical)
- Radiates to buttock or leg
- Nerve root pain often worse on coughing, strianing
- Relieved when standing
- Nerve root compression may give weakness and altered sensation to a specific myotome and dermatome
7
Q
What’s location of most disc prolapse?
A
- Most disc prolapses are posterolateral
- E.g L4-5 disc protrusion compresses L5 root
- 90% patients symptoms resolve without surgery
8
Q
Symptoms of L5 compression
A
L4/5 → L5 Root Compression
- Weak hallux extension ± foot drop
- In foot drop due to L5 radiculopathy, weak
inversion (tib. post.) helps distinguish from
peroneal n. palsy
- ↓ sensation on inner dorsum of foot
9
Q
Features of S1 root compression
A
L5/S1 → S1 Root Compression
- Weak foot plantarflexion and eversion
- Loss of ankle-jerk
- Calf pain
- ↓ sensation over sole of foot and back of calf
10
Q
Management of root compression
A
- Brief rest, analgesia and mobilisation effective in ≥90%
- Conservative: brief rest, mobilisation/physio
- Medical: analgesia, transforaminal steroid injection
- Surgical: discectomy or laminectomy may be needed in cauda- equina syndrome, if pain or muscle weakness continues
11
Q
Presentation of acute cauda equina syndrome
A
- Alternating or bilateral radicular pain in the legs
- Saddle anaesthesia
- Loss of anal tone
- Bladder ± bowel incontinence
12
Q
Treatment of cauda equina syndrome (according to different etiologies) (3)
A
- Large prolapse: laminectomy / discectomy
- Tumours: radiotherapy and steroids
- Abscesses: decompression
13
Q
What happens in cauda equina syndrome?
A
- Caused by large central disc protrusion
- Compresses all nerve roots within the cauda equina
14
Q
Ix for cauda equina syndrome
A
Urgent MRI
15
Q
Difference in anatomy of simple disc prolapse and cauda equina
A
16
Q
Red flags for cauda equina syndrome
A
- 1.Bilateral sciatica
2. Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
3. Difficulty initiating micturition or impaired sensation of urinary flow
4. Loss of sensation of rectal fullness
5. Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
6. Laxity of the anal sphincter
17
Q
High energy spinal fractures
- cause
- risk of what complication
A
- High energy trauma (young RTA)
- If back pain → immobilise and image
- Potential complication: instability and spinal cord injury
18
Q
Low energy spinal fracture
- population
- risk factors
- potential complication
A
- Low energy (elderly osteoporotic)
- Up to 50% of over 80s
- Risk: osteoporosis, any previous fractures, minor injuries etc
Risk of complication: progressive collapse and deformity
19
Q
Red flags for vertebral fracture (4)
A
- Sudden onset of severe central spinal pain which is relieved by lying down
- There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present
- There may be point tenderness over a vertebral body
20
Q
A
21
Q
Cancers that commonly metastasise to the spine?
A
- Commonly breast, lung, thyroid, kidney, prostate
22
Q
What part of spine cancers commonly metastasise to?
A
- Spine is most common site for bony metastasis
- especially thoracic spine
23
Q
Red flags for spinal pain that may be caused by cancer
A
- age >/ 50 years
- gradual onset of symptoms
- severe unremitting pain that remains when the person is supine
- aching night pain that prevents or disturbs sleep
- pain aggravated by straining
- thoracic pain.
- localised spinal tenderness.
- no symptomatic improvement after 4-6 weeks of conservative low back pain therapy
- unexplained weight loss
- past history of cancer
24
Q
(3) most common spinal infections and most common organism causing them
A
- Discitis
- Vertebral osteomyelitis
- Spinal abscess
Mostly due to: Staph Aureus
25
What anatomical location *discitis* affect?
(2) serious complications
Discitis is an infection in the **intervertebral disc**
**space**. It can lead to serious complications such as sepsis or an epidural abscess.
26
Features (symptoms) of **discitis**
* Back pain
* General features
* pyrexia,
* rigors
* sepsis
* Neurological features
* e.g. changing lower limb neurology
* if epidural abscess develops
27
Causes of discitis (organisms)
* Bacterial
* *Staphylococcus aureus* is the most common cause of discitis
* Viral
* TB
* Aseptic
28
Diagnosis of ***discitis***
* Imaging: MRI has the highest sensitivity
* CT guided biopsy may be required to guide antimicrobial treatment
* Assess the patient for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere
29
Treatment of discitis
* 6-8 weeks IV antibiotic therapy
* Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy)
30
What's osteomyelitis?
Osteomyelitis describes an infection of the bone
It can occur in the spine e.g. *vertebral osteomyelitis*
31
Causes of osteomyelitis
* ***Staph. aureus*** → the most common cause
* ***Salmonella*** species → in sickle-cell anaemia
32
Factors predisposing to osteomyelitis
* diabetes mellitus
* sickle cell anaemia
* intravenous drug user
* immunosuppression due to either medication or HIV
* alcohol excess
33
Ix for osteomyelitis
MRI is the imaging modality of choice
34
Mx for osteomyelitis
* flucloxacillin for 6 weeks
* clindamycin if penicillin-allergic
Vertebral osteomyelitis management: 4 weeks IV antibiotics and 2 weeks of oral after
35
Red flags symptoms of spinal infections
* Fever
* TB or recent UTI
* diabetes
* history of IV drug use
* HIV infection
* use of immunosuppressants
* person is otherwise immunocompromised
36
What's a spinal epidural abscess?
Spinal epidural abscess (SEA):
* a collection of pus that is superficial to the dura mater (of the meninges) that cover the spinal cord
* it's an emergency requiring urgent investigation and treatment to avoid progressive spinal cord damage
37
Causes of spinal epidural abscess
* another **infection** → bacteria enters the spinal epidural space by contiguous spread from adjacent structures (e.g. discitis), haematogenous spread from concomitant infection (e.g. bacteraemia from IVDU), or by direct infection (e.g. spinal surgery)
* **Immunosuppression**
38
Presentation of epidural abscess
Patients present with a combination:
* fever
* back pain
* focal neurological deficits according to the segment of the cord affected
39
Investigations for epidural abscess
* Bloods (including inflammatory markers, HIV, Hep B, Hep C, and preoperative blood tests (coagulation and group and screen))
* Blood cultures
* Infection screen (including chest x-ray and urine culture)
* MRI whole spine (the entire spine is imaged since skip lesions may be present)
\*If the primary source of infection is not clear, a wide search for sources requires investigations including echocardiography and dental x-rays
40
Treatment of spinal epidural abscess
* long-term course of **antibiotics** which is at first broad spectrum but maybe later refined based on culture results
* if large or compressive abscesses, significant or progressive neurological deficits or those who are not responding to antibiotics alone are considered for **surgical evacuation** of the abscess
