MSK Back Pain + CES Teaching Flashcards
what are common symptoms of cervical myelopathy
neck pain and stiffness
occipital headache
diffuse bilateral, non dermatomal paraesthesia of the extremities
bilateral weakness and decreased manual dexterity
gait instabiltiy
what can you expect to see on examination of a patient with cervical myelopathy
decreased pain sensation
proprioception dysfunction (advanced disease)
UMN signs: hyperreflexia, babinski +
Romberg’s sign
difficulty performing heel-toe walk
what is lhermitte’s sign
‘electric shock’ sensation down the spine on neck flexion
sign of cervical myelopathy
what are some causes of cervical myelopathy
degerative cervical spondylosis
- most common
- compression may be from:
osteophytes,
spondylisthesis,
ligament flavum hypertrophy
trauma,
epidural abscess,
cervical hyperkyphois
what is cervical myelopathy
a condition which describes the compression of the spinal cord at the cervical level
what imaging is suitable for cervical myelopathy
MRI
visualises the soft tissue
evaluate the degree of compression
what conservative management options are there for cervical myelopathy
NSAID, gabapentin if symptoms not improving
Physio
Immobilisation - hard collar in slight flexion
who is conservative management appropriate for with cervical myelopathy
mild disease with no functional impairment
pts who are poor candidates for surgery
what surgical options are there for cervical myelopathy
surgical decompression
for those with significant functional impairment and level 1-2 disease
what are red flag symptoms of back pain
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
what are some general differentials for back pain
muscular strain
vertebral fracture
prolapsed intervertebral disc
discitis
ankylosing spondylitis
spinal stenosis
maliganancy
what are risk factors for muscular lower back pain
heavy lifting
prolonged seating
obesity
smoking
gender
what is the management for muscular back pain
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
symptoms of CES
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
what should you examine for in suspected CES
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
what investigations are appropriate for CES
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
what is the managment for CES
emergency decompression surgery
within 24-48 hours, improves outcome for bowel/bladder dysfunction and motor/sensory deficit and chronic pain
how does lumbar disc herniation tend to present
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
what could you find on examination of a patient with lumbar disc herniation
limited ROM, pt leaning away from side of radiculopathy
straight leg raise and femoral nerve stretch
what signs would you find with radiculopathy of L4
weakness of ankle dorsiflexion
decreased patella reflex
what signs would you find with radiculopathy of L5
Extensor hallucis longus weakness
hip abduction weakness
ankle inversion weakness
what signs would you find with radiculopathy of S1
ankle plantar flexion weakness
decreased achilles tendon reflex
where do disc herniations tend to occur
L4/5 or L5/S1
what investigations can be done for a lumbar herniation
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
what are the management options for lumbar disc herniation
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
how can neurological claudication present
pain worse with extension (walking, standing)
relieved by flexion
weakness may be present
what is kemp sign
unilateral radicular pain from stenosis made worse by extension
what could you find on examination for neurological claudication
kemp sign
neurological exam may be normal
symptoms may only be present with lumbar extension
how to differentiate between neurological or vascular claudication
bicycle test - differentiates between neurogenic or vascular
what are risk factors of lumbar spinal stenosis
caucasian
high BMI
congenital spine deformities
age a usually occurs due to degenerative bone disease
what is the management for lumbar spinal stenosis
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
why do disc herniations tend to be paracentral
tends to be paracentral due to lateral edge of posterior longitudinal ligament being the weakest region
