Cortex - adult orthopaedics spine and upper limb 1 (spine) Flashcards
What is the cause of most cases of back pain ?
Mechanical back pain
Describe the presentation of mechanical back pain
Thought of as recurrent relapsing and remitting back pain with no neurological symptoms.
Pain is worse with movement (mechanical) and relieved by rest
What is the typical patient with mechanical back pain ?
Between the ages of 20-60 and have had previous flare up. No red flags
What are some of the causes of mechanical back pain ?
- Obesity
- Poor posture
- Poor lifting technique
- Lack of physical activity
- Depression
- Degenerative disc prolapse
- Facet joint OA and spondylosis.
What is the mainstay of treatment of mechanical back pain ?
Analgesia and physiotherapy. (not rest as will lead to stiffness)
In an acute intervertebral disc tear what part it torn ?
The outer annulus fibrosis
How do acute disc tears classically occur ?
After lifting a heavy object e.g. a lawnmower
What is the back pain in acute disc tears characteristically made worse by ?
Coughing
What is the treatment of acute disc tears ?
Analgesia and physiotherapy are the mainstay of treatment.
What is a potential complication of acute disc tears ?
The inner gelatinous nucleosis can herniate or prolapse through the tear and press (impinge) on an exiting nerve root
What are some of the signs that an acute disc tear has started to impinge nerve roots ?
- Pain
- Altered sensation in a dermatomal distribution as well as reduced power in a myotomal distribution.
- Reduced reflexes and motor function (LMN lesion)
What is the most common site in the spine for disc impingement to occur ?
L4, L5 and S1 nerve roots contributing to the sciatic nerve
Go over the route of spinal nerves (this will help you determine what spinal nerve route is impinged with different types of proalpses)
What is sciatica ?
Radicular pain felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee. (Note back pain can radiate to the buttock and thigh but not below the knee).
What is the first line treatment of sciatica/lumbar radiculopathy ?
Analgesia, maintaining mobility and physio
What can be added second line for more sever sciatica/ lumbar radiculopathy ?
Drugs for neuropathic pain (eg Gabapentin)
What can cause bony nerve root entrapment ?
OA of the facet joints can result in osteophytes impinging on exiting nerve roots
What is bony nerve root entrapment basically the same as in terms of symptoms ?
Herniation/prolapse of intervertebral discs esulting in nerve root symptoms and sciatica as previously discussed.
What is a potential treatment of bony nerve root entrapment ?
Surgical decompression, with trimming of the impinging osteophytes in sutiable candidates
What is spinal stenosis and its causes ?
It is an abnormal narrowing of the spinal canal - reducing the space the cauda equina has
Can be cuase by:
Spondylosis and a combination of bulging discs, bulging ligamentum flavum (ligaments of the spine connecting adjacent laminae of vertebrae) and osteophytosis
What is the characteristic presentation of spinal stenosis ?
Sufferers tend to over 60 and characteristically have claudication (pain in the legs on walking).
What is the difference in claudication due to spinal stenosis rather than PVD?
- Claudication distance is inconsistent
- The pain is burning (rather than cramping)
- Pain is less walking uphill (spine flexion creates more space for the cauda equina)
- Pedal pulses are preserved
What is the treatment of spinal stenosis ?
- 1st line - conservative management with physiotherapy and weight loss
- 2nd line - surgery may be performed (decompression to increase space for the cauda equina)
What is cauda equina syndrome and the affected nerve roots ?
It is where a very large central disc prolapse occurs which compresses all the nerve roots of the cauda equina
Affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination.
