Lumbar Spine Problems Flashcards
what is mechanical back pain
recurrent relapsing and remitting back pain with no neurological symptoms
what age do patients tend to get mechanical back pain
20 and 60
what are symptoms of mechanical back pain
worse on movement an relieved by rest
no red flags
what are red flag symptoms
non-mechanical pain
systemic upset
major, new neurological deficit
saddle anaesthesia +/- bladder or bowel upset
what causes mechanical back pain
obesity poor posture or lifting depression degenerative disc prolapse facet joint osteoarthritis spondylosis
what is spondylosis
where intervertebral discs lose water with age resulting in less cushioning and increased pressure on facet joint
leads to secondary OA
looks like scotty dog on X ray
how is mechanical back pain diagnosed
diagnosis of exclusion of nerve root problem or pathological process
how is mechanical back pain treated
analgesia
physiotherapy
NO bed rest
when only reason surgery be considered
if two adjacent vertebrae effected by oA
instability diagnosed by MRI
what is an acute disc tear / discogenic back pain
an acute tear which occurs in outer annulus fibrosis of an intervertebral disc
when does acute disc pain classically occur
after lifting heavy object (eg lawnmower)
what is symptoms of acute disc tear
pain is characteristically worse on coughing since this increases disc pressure and the periphery of disc is richly innervated
how is acute disc tear treated
analgesia and physiotherapy
symptoms usually resolve but take 2-3 months to settle
what is sciatica
disc tear occurs in L4 - S3
gelatinous nucleus pulpous can herniate or prolapse through tear
disc material can impinge on nerve root resulting in altered dermatomal sensation and myotomal power
what is general sciatica symptoms
radiating pain is felt as a neuralgic burning or severe tingling pain radiating down back of thigh to below the knee
what happens in L3/4 prolapse sciatica
L4 root entrapment
pain down medial ankle
loss of quadriceps power
reduced knee jerk
what happens in L4/5 prolapse sciatica
L5 root entrapment
pain down dorsum of foot
reduced power of extensor hallucis longus and tibialis anterior
what happens in L5/S1 prolapse
S1 root entrapment
pain to sole of foot
reduced power plantar flexion
reduced ankle jerks
how is sciatica diagnosed
positive sciatic stretch test
may have a cross over sign where sciatic stretch testing of the opposite side produces pain on affected side
what is treatment of sciatica
analgesia
maintaining mobility
physiotherapy
(occasionally drug for neuropathic pain eg gabapentin used if leg pain severe)
when would discectomy be indicated in sciatica
very occasionally
pain not resolving
localising signs suggesting specific nerve root involvement
positive MRI of nerve root compression
the surgery is for the LEG PAIN, not back pain
what is bony nerve root entrapment
when OA of facet joints can results in osteophytes impinging on exiting nerve roots
what symptoms does bony nerve root entrapment result in
nerve root symptoms and sciatica as previously mentioned
what is treatment of bony nerve root entrapment
surgical decompression, with trimming of the impinging osteophytes, may be performed on suitable candidates
what is spinal stenosis
with spondylosis and a combo of bulging discs, bulging ligament flavum and osteophytosis, the cauda equina of lumbar spine has less space - stenosis
what is a result of this narrowing of space (spinal stenosis)
multiple nerve roots can be compromised / irritated
what age to sufferers of spinal stenosis tend to be
over 60
what are symptoms of spinal stenosis
claudication (pain in legs on walking)
what is difference between the claudication in spinal stenosis and that of PVD
in spinal stenosis:
- claudication distance is inconsistent
- pain is burning (rather than cramping)
- pain is less walking uphill (spinal flexion creates more space for cauda equina)
- pedal pulses are preserved
how is spinal stenosis treated
conservative = physio and weight loss
this fails and MRI evidence of stenosis = surgical decompression to increase space for cauda equina
what is cauda equina syndrome
emergency whereby a very large disc prolapse compresses all nerve roots of cauda equine
what are the main sacral roots that are effected in cauda equina
S4 and S5 controlling defaecation and urination
what are symptoms of cauda equina syndrome
bilateral leg pain
parasthesiae or numbness
“saddle anaesthesia” - numbness around sitting area and perineum
altered urinary / bowel function (retention or incontinence)
how is cauda equina diagnosed
PR exam mandatory!
urgent MRI required to determine level of prolapse
how is cauda equina treated
surgical emergency - discectomy required once diagnosis confirmed
what can be a complication of cauda equina
residual nerve injury with permanent bladder and bowel function
urgent surgery may prevent this
if it does happen = colostomy and urinary diversion
back pain in younger patient (<20) is red flag, what can it suggest
osteomyelitis, discitis
spondylolisthesis (slipped vertebrae)
benign or malignant tumours
should probably refer or arrange MRI
back pain in older patient (>60) is also a red flag, what can it suggest
arthritic change or crush factor
metastatic disease from breast, bronchus, prostate, thyroid or kidneys
what does pain from a tumour tend to be
constant, unremitting, severe and worse at night
also have systemic upset
if you have a red flag, what may you want to do
bloods spine x ray (may show collapse or loss of a pedicle on AP view) CXR bone scan MRI scan
what is an osteoporotic crush fracture
with severe osteoporosis, spontaneous crush fractures of vertebral body can occur
what is symptom of osteoporotic crush fracture
acute pain and kyphosis (extreme curvature - hump)
how is osteoporotic crush fracture diagnosed
plain xray
might want to consider MRI, bone scan or CT
how is osteoporotic crush fracture treated
usually conservative (rest and pain meds) = get better in 3 months without specific treatment
what have some clinicians tried in an attempt to treat chronic pain from osteoporotic crush fractures but the long term results not fully evaluated
balloon vertebroplasty (inserting balloon into vertebral body under fluoroscopic guidance, inflating balloon to lift corticies of vertebral body and injecting cement to fill void)
