Disease Profiles: Back Pain Flashcards
Describe the management of osteoporotic crush fractures
Usually conservative, may consider balloon vertebroplasty
Name a genetic condition that predisposes to atraumatic cervical spine instability
Down’s syndrome
Describe the examination findings of a patient with sciatica
Nerve irritation signs
Motor, sensory, or reflex changes in one nerve root
Describe the examination findings of a patient with vertebral osteomyelitis
Paraspinal muscle spasm, spinal tenderness, fever/systemic upset, neurological deficit in severe cases
When is spinal stabilisation surgery indicated for mechanical back pain?
Only indicated if a single vertebral level is affected by OA or instability, and the patient has not improved despite physio and conservative management and there are no other adverse secondary gain or behavioural issues which adversely affect outcome of surgery
When would you consider surgery for sciatica?
If unremitting/recurrent symptoms
What percentage of patients will be better within 6 weeks of mechanical back pain?
90%
Why must you ensure MRI findings correlate with clinical findings before considering surgery for a suspected cervical disc prolapse?
The number of patients with asymptomatic disc prolapse increases with age resulting in a higher rate of false positives/incidental findings on MRI scanning
What affect will walking downhill have on a patient with spinal stenosis?
Exacerbates symptoms
What investigation would you perform in suspected cauda equina syndrome?
Urgent MRI to determine level of prolapse
How would you manage a less severe atlanto-axial subluxation?
Collar to prevent flexion
Describe the management of cervical spondylosis
Physiotherapy and analgesia
How would you investigate cervical spine instability?
X-ray (flexion-extension views)
Why is spinal stabilisation surgery only suitable for a minority of mechanical back pain?
Most patients have multi‐level disease of the spine for which there is no role for surgery
Describe the non-surgical management of a patient with vertebral osteomyelitis
High dose IV antibiotics appropriate to tissue culture
Describe the usual management of mechanical back pain
Lifestyle advice - aim to walk 30 mins a day, stay at work, restrict activity rather than avoid, weight control
Analgesia - NSAIDs first line, weak opiates if needed
Physiotherapy
How would you manage a severe atlanto-axial subluxation?
Surgical fusion
What affect will walking uphill have on a patient with spinal stenosis?
Relieves symptoms
Describe the management of an acute disc tear
Analgesia and physio
Symptoms usually resolve but can take 2-3 months
What causes spondylosis?
IV discs lose water content with age, resulting in less cushioning and increased pressure on the facet joint which can lead to secondary OA
Describe the management of vertebral TB
As for pulmonary TB
Analgesia
May require surgery - immobilisation of spine region, drainage of spinal abscesses
What causes osteoporotic crush fractures?
With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis
Can lead to chronic pain due to altered spinal mechanics
What investigations would you perform in suspected vertebral osteomyelitis?
Bloods - raised CRP, blood culture
MRI - extent of infection, abscess formation
CT guided biopsy - tissue culture
Describe the clinical presentation of vertebral TB
Slow and insidious back pain, lower limb weakness/paraplegia, kyphotic deformity
1/2 have skin and soft tissue infection, less than 1/2 have pulmonary TB
Describe the clinical presentation of vertebral osteomyelitis
Insidious onset of back pain (most commonly lumbar) which is constant and unremitting
Why is back pain from an acute disc tear worse on coughing?
Coughing increases disc pressure
What investigation would you perform in a suspected cervical disc prolapse?
MRI
What is spondylosis?
Spinal osteoarthritis
How can rheumatoid arthritis cause lower cervical subluxations?
Destruction of the synovial facet joints and uncovertebral joints
Describe the management of a cervical disc prolapse
Conservative - analgesia and therapy
Surgery - consider in cases resistant to conservative management
Describe the clinical presentation of mechanical back pain
Pain in lumbosacral region, buttocks and thighs that varies with time and activity
Patient tends to have had several previous ‘flare ups’
No red flags
What patient group is most likely to develop mechanical back pain?
Age 20-55, obese
Why are IV discs more prone to prolapse (herniate) in older patients?
As a result of aging the discs become dehydrated and weaken
How would you manage a less severe lower cervical subluxation?
Conservative - analgesia, physio
How would you manage a severe lower cervical subluxation?
Consider stabilisation/fusion
Describe the clinical presentation of cauda equina syndrome
Classically bilateral leg pain (can be unilateral or with no leg symptoms), loss of motor or sensory function of bowel/bladder, saddle anaesthesia, motor weakness in the legs or gait distribution
What often causes IV disc herniation?
Strenuous physical activity involving the lumbar spine in an older patient
Describe the management of cauda equina syndrome
Urgent discectomy
Describe the clinical presentation of sciatica
Unilateral leg pain that is greater than the back pain, sharp, shooting electric pain, pain radiates to foot, numbness and parasthesia in the same distribution
Why is new back pain in an older patient (> 60 years) considered a red flag?
Higher risk of neoplasia - particularly metastatic disease and multiple myeloma
If the C6/7 IV disc prolapses, which nerve root is more likely to be involved?
C7
What is the most common causative organism for vertebral osteomyelitis?
Staph. aureus
Describe the management of bony nerve root entrapment
Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates
Which nerve root is most commonly compressed in sciatica?
L5/S1
Describe the clinical presentation of spinal stenosis
Pain in the legs on walking (claudication), pain is burning in nature
What is bony nerve root entrapment?
OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica
Describe the surgical management of vertebral osteomyelitis
Debridement, stabilization and fusion of adjacent vertebrae
Describe the conservative management of spinal stenosis
Analgesia, physiotherapy, weight loss if indicated
What is an acute disc tear?
Acute tear in the outer fibrosis of an IV disc which classically happens after lifting a heavy object (e.g. lawnmover)
What cardiac condition can cause vertebral osteomyelitis?
Endocarditis
What is vertebral osteomyelitis?
Infection of the vertebrae
How would you investigate vertebral TB?
X-ray, MRI
Check for immunosuppression/HIV
What is spinal stenosis?
Narrowing of the central spinal canal, IV foramen and/or lateral recess causing progressive nerve root compression
What causes sciatica?
Compression of a nerve root, most commonly L5/S1
Usually due to prolapse of a disc which impinges on the nerve root
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms
What examination would you perform in suspected cauda equina syndrome and what would you expect to see?
PR exam - loss of anal sphincter tone
How can rheumatoid arthritis cause atlanto-axial subluxation?
Destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament
What is sciatica?
Characteristic pain felt in the lower back, buttocks and the posterior and lower leg that results from compression of any of the 5 nerve roots that contribute to the sciatic nerves
Describe the surgical management of spinal stenosis
Decompression to increase space for the cauda equina
Why is constant, severe back pain worse at night considered a red flag?
Suggests tumour or infection rather than mechanical cause
Describe the clinical presentation of a cervical disc prolapse
Shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected
A large central prolapse can compress the cord leading to a myelopathy with upper motor neurone symptoms and signs
Describe the normal management of sciatica
90% resolve spontaneously within 3 months - advise NSAIDs and analgesia
Describe the clinical presentation of cervical spondylosis
Slow onset stiffness and pain in the neck, pain can radiate to shoulders and occiput
Name the indications for surgery in vertebral osteomyelitis
Inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit
What is cauda equina syndrome?
A very large central disc prolapse compresses all the nerve roots of the cauda equina
What is Pott disease?
Vertebral body osteomyelitis and intervertebral discitis from tuberculosis (TB)
Describe osteophytes as a complication of cervical spondylosis
Osteophytes can impinge on the exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes - may require surgical decompression
What causes cervical spondylosis?
As with the rest of the spine, spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints
Why is back pain from an acute disc tear severe?
The periphery of the disc is richly innervated
Why is back pain with associated systemic upset (fever, night sweats, weight loss etc.) considered a red flag?
May suggest underlying tumour or infection
What causes spinal stenosis?
Mainly caused by degenerative joint disease in middle aged to elderly individuals - spondylosis, bulging discs, bulging ligamentum flavum and osteophytosis
Why is cauda equina syndrome a surgical emergency?
Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion
What is the most common route of spread for vertebral osteomyelitis?
Haematogenous
Why is back pain in a younger patient (> 20 years) considered a red flag?
Children - more susceptible to infections e.g. osteomyelitis
Adolescents - peak age for spondylolisthesis and some benign and malignant bone tumours
When would you consider surgical management of spinal stenosis?
If symptoms fail to resolve with conservative management and there is MRI evidence of stenosis
