MSK Back Pain + CES Teaching Flashcards

1
Q

what are common symptoms of cervical myelopathy

A

neck pain and stiffness
occipital headache
diffuse bilateral, non dermatomal paraesthesia of the extremities
bilateral weakness and decreased manual dexterity
gait instabiltiy

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2
Q

what can you expect to see on examination of a patient with cervical myelopathy

A

decreased pain sensation
proprioception dysfunction (advanced disease)
UMN signs: hyperreflexia, babinski +
Romberg’s sign
difficulty performing heel-toe walk

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3
Q

what is lhermitte’s sign

A

‘electric shock’ sensation down the spine on neck flexion
sign of cervical myelopathy

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4
Q

what are some causes of cervical myelopathy

A

degerative cervical spondylosis
- most common
- compression may be from:
osteophytes,
spondylisthesis,
ligament flavum hypertrophy
trauma,
epidural abscess,
cervical hyperkyphois

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5
Q

what is cervical myelopathy

A

a condition which describes the compression of the spinal cord at the cervical level

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6
Q

what imaging is suitable for cervical myelopathy

A

MRI
visualises the soft tissue
evaluate the degree of compression

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7
Q

what conservative management options are there for cervical myelopathy

A

NSAID, gabapentin if symptoms not improving
Physio
Immobilisation - hard collar in slight flexion

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8
Q

who is conservative management appropriate for with cervical myelopathy

A

mild disease with no functional impairment
pts who are poor candidates for surgery

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9
Q

what surgical options are there for cervical myelopathy

A

surgical decompression
for those with significant functional impairment and level 1-2 disease

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10
Q

what are red flag symptoms of back pain

A

thoracic pain
fever and unexplained weight loss
bladder/ bowel incontinence
painless urinary retention
Hx of malignancy
progressive neurological deficit
disturbed gait
saddle anaesthesia
<20yrs, >55yrs

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11
Q

what are some general differentials for back pain

A

muscular strain
vertebral fracture
prolapsed intervertebral disc
discitis
ankylosing spondylitis
spinal stenosis
maliganancy

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12
Q

what are risk factors for muscular lower back pain

A

heavy lifting
prolonged seating
obesity
smoking
gender

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13
Q

what is the management for muscular back pain

A

analgesia - NSAIDs, paracetamol, codeine
avoid heavy lifting
physiotherapy
saftey net
follow up in 2/52 to assess progress

imaging can be done if no improvement over 1 month or red flag symptoms preseny

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14
Q

symptoms of CES

A

lower back pain, can be the only symptom in early disease
unilateral/bilateral sciatica, motor or sensory symptoms
saddle anaesthesia
incontinence
painless urinary retention
erectile dysfunction

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15
Q

what should you examine for in suspected CES

A

reduced anal tone
uni/billateral lower limb weakness
reduced/absence sensation of the perineum, perianal reigon and posterior thigh
palpate bladder to check for retention

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16
Q

what investigations are appropriate for CES

A

urgent MRI
FBC, CRP/ESR to rule out infective causes
check recent invasive procedures/ anticoagulant use to rule out haematoma cause
red flags for malignancy/ mets

17
Q

what is the managment for CES

A

emergency decompression surgery
within 24-48 hours, improves outcome for bowel/bladder dysfunction and motor/sensory deficit and chronic pain

18
Q

how does lumbar disc herniation tend to present

A

sudden onset of pain, typically following heavy lifting
symptoms improve when lying supine with hips and knees flexed
radicular pain improves with standing
worsens with coughing, sneezing
unchanged by movement

19
Q

what could you find on examination of a patient with lumbar disc herniation

A

limited ROM, pt leaning away from side of radiculopathy
straight leg raise and femoral nerve stretch

20
Q

what signs would you find with radiculopathy of L4

A

weakness of ankle dorsiflexion
decreased patella reflex

21
Q

what signs would you find with radiculopathy of L5

A

Extensor hallucis longus weakness
hip abduction weakness
ankle inversion weakness

22
Q

what signs would you find with radiculopathy of S1

A

ankle plantar flexion weakness
decreased achilles tendon reflex

23
Q

where do disc herniations tend to occur

A

L4/5 or L5/S1

24
Q

what investigations can be done for a lumbar herniation

A

diagnosis from history and examination
AP and lateral XR to exclude other pathologies

diagnosis confirmed with MRI
if there are red flags present or pain for 1 month not responding to conservative treatment

25
Q

what are the management options for lumbar disc herniation

A

if no red flags or significant motor issues then conservative: rest, physio, analgesia
90% of patients improve without surgery

if conservative treatment failed then nerve root corticosteroid injections

then surgery: laminectomy and discectomy

26
Q

how can neurological claudication present

A

pain worse with extension (walking, standing)
relieved by flexion
weakness may be present

27
Q

what is kemp sign

A

unilateral radicular pain from stenosis made worse by extension

28
Q

what could you find on examination for neurological claudication

A

kemp sign
neurological exam may be normal
symptoms may only be present with lumbar extension

29
Q

how to differentiate between neurological or vascular claudication

A

bicycle test - differentiates between neurogenic or vascular

30
Q

what are risk factors of lumbar spinal stenosis

A

caucasian
high BMI
congenital spine deformities
age a usually occurs due to degenerative bone disease

31
Q

what is the management for lumbar spinal stenosis

A

conservative: weight loss, NSAIDs, physio and bracing
steroid injections

surgical if pain doesn’t improve within 6 months, progressive of neurological issues

wide pedicle to pedicle decompression

32
Q

why do disc herniations tend to be paracentral

A

tends to be paracentral due to lateral edge of posterior longitudinal ligament being the weakest region