Lumbar Spine Flashcards
Following a lumbar disc prolapse, patients who are suitable for surgery usually have it after what period of time?
26 weeks after the onset of pain
Should patients with chronic pain be considered for surgery?
No
Give the red flags for spinal pathology? (8)
Aged < 20 or > 60 with NEW back pain, non-mechanical, history of cancer, history of steroid use, systemic upset, structural deformity, signs of cauda equina, severe pain for 6+ weeks
Cauda equina syndrome is time sensitive. How soon does it need to be treated?
Within 48 hours
What can damage to the growth plate in adolescence cause?
Premature fusion and cessation of growth which can lead to kyphosis
What are chance fractures?
Highly unstable fractures
What happens if a spinal fracture occurs in ankylosing spondylitis?
This is a very dangerous and unstable injury which may be made worse with a collar. Always keep their neck in their natural position.
What test should always be done in a fracture in a patient with ankylosing spondylitis?
CT
What are the outcomes of spinal fractures in AS?
Poor outcomes, often don’t heal, can cause pseudotumours
Straight leg raise should be tested if you suspect what diagnosis?
Sciatica
What is the 1st line investigation for back pain if there are red flags present?
MRI
> 90% of cases of back pain are what?
Mechanical pain
What are some management options for mechanical back pain?
Explanation and reassurance, encourage to mobilise, analgesics, muscle relaxants, physiotherapy, osteopathy and chiropractor
What is the role of NSAIDs in the management of mechanical back pain?
Can be used short term
What % of cases of prolapsed discs will settle alone?
70-90%
When is a prolapsed disc an emergency?
Cauda equina syndrome
The long term results of a prolapsed disc are the same whether operated on or not. True or false?
True
Who is claudication as a result of spinal stenosis most likely to occur in?
Males aged 50+, associated with obesity
What activities will be possible in someone with claudication as a result of spinal stenosis?
Cycling, and going uphill when walking is easier than downhill
When will discogenic pain be worse?
By the end of the day, on moving and on flexion
Myelograms are rarely used now, what condition can they show?
Spinal stenosis
What are some symptoms of facet arthropathy?
Morning stiffness, pain which is worse with extension and at rest, better with activity and may radiate to the legs
Is imaging required for non-specific low back pain?
No
What are some behavioural (yellow flags) for back pain?
Low mood, high levels of pain/disability, belief that activity is harmful, obesity, litigation, job problems
When assessing back pain, as well as physical factors, what else should be included in the history?
Occupation, social factors and litigation
Why should you be suspicious of patients who know exactly when their back pain comes on?
Because back pain is usually insidious
Pain which is worse when is generally a concern?
At night
What movement will accentuate any structural spinal deformity?
Forward bending
Pain from sciatica will be in what pattern?
Dermatomal
If a patient is struggling to straight leg raise, what should you get them to do which is essentially exactly the same thing?
Sit up at 90 degrees with their legs straight infront
Should pushing downwards on a patients head (axial pressure) cause any back pain?
No
What is a downside of MRI for back pain?
It can give a lot of false positives
X-rays are usually pretty useless for spinal disease, what condition can they show?
Spinal stenosis
CT scans are good for showing what?
Inflammation
What can be done to manage severe back pain in the pain clinic?
Nerve block/ablation
What is a common presentation of disc prolapse?
Episodic back pain, leg pain and neurology (related to dermatomes and myotomes)
How many cases of disc prolapse will settle in the first 3 months? How many in 18-24 months?
3 months- 70%, 18-24 months- 90%
Patients with sciatica will generally have surgery if there is no improvement after how long?
3 months
What is the failure rate of surgery for back pain?
25%, with 3-5% coming out worse off
What are some adverse indicators to surgery for back pain?
Litigation, benefit claims, chronic pain syndromes/behaviours
There is increasing evidence of a link between back pain and what experiences?
Childhood abuse, PTSD, white coat stress
What conditions can make back pain seem worse? What can often make it better in these cases?
Anxiety and depression, distraction can make it better
The majority of cases of scoliosis are caused by what?
Idiopathic
Early onset idiopathic scoliosis is defined as below what age?
7
What is a common theme in scoliosis and spinal deformity?
Imbalance of the number of growth plates
What are some conditions which scoliosis can be secondary to?
Neuromuscular conditions, tumours, spina bifida
When are surgical treatments given for scoliosis and spinal deformity?
When conservative treatment has failed, adolescents with a > 50% slip, neurological deficit, postural deformity
What is spondylolysis?
Defect or stress fracture of the vertebral arch
What is spondylolisthesis?
Forward slippage of one vertebrae on another
In osteoarthritis of the facet joints, which movement makes pain worse?
Extension of the spine
If a specific joint is implicated in spinal OA, what treatment may help?
Facet joint injections
OA in one or two segments can be treated with what? What is the disadvantage to this?
Fusion- will affect the adjacent level in around 5 years time
Both mechanical back pain and sciatica can radiate to the thighs and buttock. How can you tell these apart?
Only pain from sciatica will go below the knee
What is often the cause of mechanical back pain?
Awkward twisting or poor lifting technique leading to acute muscular or ligamentous strain or sprain
What are some non-pathological factors that mechanical back pain may be related to?
Obesity, lack of physical activity, early OA
Will there be neurological symptoms in mechanical back pain?
No
When is mechanical back pain generally better and worse?
Better with rest, worse on movement
What is spondylosis?
Essentially OA; intervertebral discs lose water content resulting in less cushioning and increased pressure on the facet joints
Is bed rest advised in mechanical back pain? Why/why not?
No- this can lead to stiffness and spasm which may make it worse
If there is single level OA or instability which has not improved with conservative management and there are no adverse indicators to surgery, what can be done very rarely?
Stabilisation surgery
Is there a role for surgery in multiple-level OA or spinal instability?
No
Effects of spinal stabilisation surgery will generally last how long?
5 years
Where does an acute disc tear occur?
The outer annulus fibrosis of an intervertebral disc
When does an acute disc tear typically occur?
After lifting a heavy object
Why is an acute disc tear so painful?
The outside of the disc is highly innervated
When is pain from an acute disc tear typically worse?
Coughing, as this increases pressure on the disc
How long can it take for symptoms of an acute disc tear to settle?
3 months
What are the mainstay of treatment for an acute disc tear?
Analgesia and physiotherapy
What makes a lumbar radiculopathy or sciatica different from just a disc tear?
In these cases, the nucleus purposes herniates out through the tear which may impinge on the exiting nerve root
What neurological symptoms may be present in a lumbar radiculopathy or sciatica?
Pain and altered sensation in a dermatomal pattern, reduced power in a myotomal pattern
What may happen to reflexes in lumbar radiculopathy/sciatica?
Reduced
What nerve roots contribute to the sciatic nerve and can cause sciatica?
L4, L5, S1
The pain from sciatica can radiate to where, where mechanical back pain cannot?
Below the knee
What are the first steps of management for lumbar radiculopathy or sciatica?
Analgesia, maintaining mobility, physiotherapy
If the pain from lumbar radiculopathy/sciatica is extremely severe, what analgesia can be used?
Neuropathic painkiller e.g. gabapentin
When may a discectomy be indicated for lumbar radiculopathy/sciatica?
Pain is not resolving, specific nerve root involvement, positive MRI of root compression
What is bony nerve root entrapment?
OA of the facet joints can cause osteophytes to impinge on the exiting nerve roots
In suitable candidates, what surgical management can be used for bony nerve root entrapment?
Surgical decompression or trimming of osteophytes
What makes claudication from spinal stenosis different from PVD?
Claudication distance is inconsistent, pain is burning, less painful going uphill, pedal pulses are present
What surgery may be used in spinal stenosis in suitable candidates?
Surgical decompression to give the caudal equina more space
What happens in caudal equina syndrome?
A large central disc prolapse compresses the nerve roots of the caudal equina
Why is caudal equina syndrome an emergency?
The affected nerve roots include the sacral roots (especially S4/S5) which control urination and defaecation
What can prolonged compression in caudal equina syndrome cause?
Permanent nerve damage requiring colostomy and urinary diversion
What surgery is needed urgently in cauda equina syndrome?
Urgent discectomy
What are some symptoms of cause equina syndrome in terms of pain/neurology?
Bilateral leg pain, parasthesia or numbness and ‘saddle parasthaesia’- numbness around the sitting area and perineum
What are some symptoms of caudal equina syndrome in terms of urination and defaecation?
Usually urinary retention but incontinence can also occur, faecal incontinence and constipation
Which patient is caudal equina syndrome until proven otherwise?
Bilateral leg pain with suggestion of altered bladder or bowel function
What examination is necessary in caudal equina syndrome?
PR exam
What test is used to assess the level of the prolapse in cauda equina syndrome?
MRI
Younger children are more susceptible to what?
Infection (osteomyelitis, discitis)
Adolescents are at the peak age for what?
Spondylolisthesis or benign (osteoid osteoma) or malignant (osteosarcoma) tumours
Patients aged 60+ are more at risk of what conditions?
OA, crush fractures, malignancy
A malignancy in the spine in older patient is more likely to be what?
Metastases or multiple myeloma
Constant, severe pain which is worse at night is more suggestive of what conditions?
Tumours or infection
What are some investigations which should be done in an individual with back pain red flags?
Bloods, spinal x-ray, chest x-ray, bone scan, MRI
What fractures can occur in severe spinal OA?
Spontaneous crush fractures of the vertebral body
What can OA crush fractures lead to?
Acute pain and kyphosis, a minority go on to have chronic pain
