Low back pain and sciatica Flashcards
What are the red flags of back pain?
Age <20 or >55 with new onset pain Systemic: weight loss, fever, night sweats Immunocompromised: steroid use History of malignancy Recent trauma IVDU
Thoracic pain
Non-mechanical back pain
New onset severe progressive back pain
Nocturnal pain and sleep disturbance
Widespread neuropathy: saddle anaesthesia
Abnormal gait
Incontinence, urinary retention, sexual problems
Which red flag symptoms are suggestive of cauda equina?
Abnormal gait
Severe or progressive bilateral leg weakness
Widespread neuropathy
Saddle anaesthesia
Reduced anal tone
Incontinence, urinary retention, sexual problems
Which red flag symptoms are suggestive of malignancy?
Age >55 with new onset pain
History of malignancy
Systemic: weight loss, fever, night sweats
Nocturnal pain and sleep disturbance
Progressive severe back pain: remains when supine
Localised spinal tenderness
Which cancers most commonly cause secondary bone cancer?
Breast Lung Thyroid Kidney Prostate Colorectal
Which red flag symptoms are suggestive of spinal fracture?
Recent trauma
Sudden onset severe central spinal pain: relieved when supine
Structural deformity of spine
Point tenderness over vertebral body
Which red flag symptoms are suggestive of spinal infection?
Fever/rigors Non-mechanical back pain TB or recent UTI Diabetes IVDU HIV or immunosuppression: long-term steroid use
Define yellow flag symptoms
Psychosocial factors shown to be indicative of long term chronicity and disability
List the yellow flag symptoms for back pain
Negative attitude
Fear avoidance behaviour and reduced activity
Expectation that passive treatment is beneficial
Tendency to depression, low morale, withdrawal
Social or financial problems: including compensation
What red flag symptoms are suggestive of cord compression?
Non-mechanical back pain Thoracic pain Incontinence, urinary retention, sexual dysfunction Hx of malignancy Widespread neurology Progressive neurology
Outline the MRC power grading classification
5: normal power
4: active movement against gravity and resistance, but less than full power
3: active movement against gravity only
2: active movement with gravity eliminated
1: flicker
0: no movement
List the types of specific back pain
Traumatic: fracture, dislocation
Neoplastic: metastasis, primary
Infective: infective spondylodiscitis
Inflammatory: inflammatory spondyloarthropathy
Metabolic: osteomalacia, osteoporosis, hyperparathyroidism, Paget’s disease
What are occupational black flags?
Obstacles to recovery
Name 3 occupational black flags
Industrial injury/litigation
Poor work satisfaction/industrial relations
Repetitive manual work
Differentiate between Upper motor neurone and Lower motor neurone lesions
Upper (CNS) vs Lower (nerve roots)
Muscle bulk: normal vs wasted (fasciculations)
Tone: increased vs decreased
Power: normal vs weak
Reflex: increased + Babinski vs decreased/absent
Special reflexes (UMNL): Hoffman and Clonus
Coordination: lost vs lost
Define Cauda Equina Syndrome
A collection of progressive neuro-deficit symptoms due to damage to the Cauda equina, including:
- Bilateral/unilateral sciatica
- Saddle anaesthesia
- Urinary retention, faecal incontinence, sexual dysfunction
Describe the prognosis of Cauda Equina if untreated
Progressive neuro-deficits leads to permanent loss of sphincter control with motor paralysis and sensory loss of legs.
Prognosis is better with decompression before sphincter paralysis.
Once paralysis develops, recovery is uncertain and likely to be incomplete.
How is Cauda Equina Syndrome confirmed?
Emergency MRI scan to confirm diagnosis, determine level of compression and any underlying cause.
Name 4 causes of Cauda Equina Syndrome
Herniation of a lumbar disc* at L4/L5 and L5/S1
Tumours: metastases, lymphomas, spinal tumours
Trauma
Infection: including epidural abscess
Congenital: congenital spinal stenosis, spina bifida
Late-stage ankylosing spondylitis
Post-op haematoma
Sarcoidosis
How is Cauda Equina Syndrome managed?
Immobilise spine if due to trauma
Emergency surgical decompression
Lesion debunking of SOL e.g. tumour or abscess
What investigation is useful for monitoring Cauda Equina Syndrome after surgical decompression?
Bladder scan to assess return of bladder function after surgical decompression.
Differentiate spinal tumours and spinal infections on MRI
Spinal tumours affect the vertebral bodies, but preserves the intervertebral discs due to lack of blood supply.
Spinal infections affect the intervertebral discs due to lack of immune cells, but preserves the vertebral bodies.
What are the commonest cancers affecting the spine?
Metastases: breast, lung, thyroid, renal, prostate
Myeloma
How is spinal metastasis investigated?
If unsure about spine stability: lie patient down
MRI entire spine
Staging/diagnostic CT of chest, abdomen, pelvis
FBC, U&Es, serum calcium, clotting
Myeloma screen, other tumour markers
Outline the treatment of spinal metastasis
Dexamethasone 16mg/d Keep patient supine if spine unstable Surgery indicated for -spinal stabilisation -decompression of cord compression -severe pain from mechanical instability
Name the 2 commonest causes of spinal infection
Tuberculosis
Staph aureus
Which locations are most commonly affected with spinal infection?
Vertebral end-plates
Adjacent disc and vertebral body
Describe the pathology of spinal infection
Bony destruction leading to vertebral collapse.
Progressive kyphosis, extradural and paravertebral abscess.
How is spinal infection diagnosed?
Blood culture or sputum sample
Trucut needle biopsy
What is the treatment for spinal infection?
Antibiotics
TB: 6-12 months
Non-TB: 6-12 weeks
Surgery
What are the indications for surgical intervention in spinal infection?
Paralysis from spinal cord compression or cauda equina syndrome
Drain paravertebral abscess
Mechanical instability: progressive deformity, severe pain
Define cervical spondylosis with myelopathy
Progressive damage to cervical spinal cord due to central stenosis caused by wear and tear.
Describe the presentation of cervical spondylosis with myelopathy
Progressive in 90% over 5-years.
Worsening sensory/motor loss with incoordination, loss of dexterity, and poor balance.
UMN signs: increased tone and reflexes (+ve Babinski), +ve Hoffman sign and Clonus
What is the definitive management of cervical spondylosis with myelopathy?
Surgical decompression of spinal cord: prevent progression of neurological-deficit and incoordination.
Describe the clinical features of vascular claudication
Pain distal to proximal
Commonly unilateral
Relieved on standing
Relieved in seconds
Describe the clinical features of neurogenic claudication
Pain proximal to distal Commonly bilateral Sudden onset on standing or walking Relieved on sitting Relieved in minutes Associated with paraesthesia, numbness, weakness
Describe the pathogenesis of neurogenic claudication
Lumbar spinal stenosis due to wear and tear and arthritic changes.
Name 2 signs on examination of neurogenic claudication
Flexed posture (Shopping cart sign): slightly opens spinal canal and relieves the pressure on the nerve roots. Loss of lumbar lordosis Pulses present
Describe the presentation of sciatica
Sudden onset (usually)
Specific localised foot pain
-L3/4 - L4 root: anterior thigh to knee, shin
-L4/5 - L5 root: lateral calf, medial/dorsal foot
-L5/S1 - S1 root: posterior calf, lateral/plantar foot
Often associated with paraesthesia
Outline the initial management of sciatica
80% self-resolve within 3 months
Bedrest for 2-3 days
Stay active and mobile within limits
NSAIDs, Codeine-based opiates
Gabapentin, Pregabalin
What secondary treatment options exist for sciatica if medical treatment fails?
Epidural or nerve root block
Lumbar discectomy
Outline the initial non-pharmacological treatment for low back pain and sciatica
Education and specific exercises. Consider NHS group-exercise programmes.
Promote and facilitate return to work and ADLs
Combined physical and psychological programme for persistent back pain
Consider manual therapy as part of package
Outline the pharmacological treatment of low back pain
Oral NSAIDs
Weak opioids: acute back pain only
Do not offer paracetamol alone
Outline the non-surgical and surgical options for low back pain
Epidural (anaesthetic + steroid): acute severe sciatica
-avoid in central spinal canal stenosis
Radiofrequency denervation: chronic low back pain
Spinal decompression
