Neck and back pain 2

Question 1

What is lumbar disc prolapse?

Answer 1

central disc gel extrudes into a fissure in the surrounding fibrous zone and causes acute pain and muscle spasm

disc prolapse = when the extrusion extends beyond the limits of the fibrous zone. weakest point is posterolateral, where the disc may impinge on spinal roots

Question 2

How does lumbar disc prolapse present?

Answer 2

starts during lifting, twisting or bending 
lower back pain radiating to the buttock
muscle spasm 
severe lancinating pains
parathesia and numbness in one leg

Question 3

What would be seen on examination in lumbar disc prolapse?

Answer 3

scoliosis and muscle spasm
positive straight leg raise test
cauda equina - perianal sensory loss
positive femoral stretch test suggests upper lumbar disc prolapse

Question 4

What is spinal and root canal stenosis?

Answer 4

caused by progressive loss of disc height, osteoarthritis of facet joints, posterolateral osteophytes and hypertrophy of ligamentum flavam

Question 5

How does nerve root pain or spinal root claudication present?

Answer 5

pain and paraesthesia in a root distribution brought on by walking and relieved slowly by rest

Question 6

What differentiates spinal root claudication from arterial claudication?

Answer 6

slow recovery when the patient rests and presence of normal foot pulses

Question 7

What are the symptoms of spinal canal stenosis?

Answer 7

bilateral leg and buttock pain
paraesthesia and numbness when walking
rest and bending forwards helps

Question 8

What is spondylosis/spondylolisthesis?

Answer 8

occurs in adolescents and young adults due to the pars interarticularis defects causing instability and permit the vertebra to slip +/- preceding injury

Question 9

What are the risks associated with spondylosis/spondylolisthesis?

Answer 9

cauda equina syndrome with loss of bladder and bowel function
needs careful monitoring during the growth spurt

Question 10

What is disseminated idiopathic skeletal hyperostosis?

Answer 10

bony overgrowths and ligamentous ossification affecting the spine and extraspinal locations
extensive xray changes
patients have a stiff back that isn’t always painful

Question 11

How does inflammatory back pain present?

Answer 11

insidious onset primarily of stiffness associated with pain
worse in the morning and with inactivity, relieved by activity
radiates bilaterally
multiple spinal segments
may be associated with weight loss and tiredness

Question 12

What other conditions are associated with inflammatory back pain?

Answer 12

anterior uveitis 
psoriasis 
IBD
Erythema nodosum 
Enthesopathy 
Juvenille oligoarticular problem

Question 13

What are the causes of inflammatory back pain?

Answer 13

infective lesions of the spine

ankylosing spondylitis/sacroiliitis

Question 14

What are the causes of metabolic back pain?

Answer 14

osteoporotic spinal fractures
osteomalacia
paget’s disease

Question 15

What are the causes of osteoporotic spinal fractures?

Answer 15

develop without trauma, after minimal trauma, or as part of a major accident

Question 16

How do osteoporotic spinal fractures present?

Answer 16

can be asymptomatic

may cause agonising localised pain, radiating around the ribs and abdomen

Question 17

How does neoplastic back pain present?

Answer 17

bony pain over a single spinal segment 
night pain 
progressive unrelated to movement 
no relieving or exacerbating factors 
can't be reproduced on examination

Question 18

What are the causes of neoplastic back pain?

Answer 18

metastases
primary tumours
multiple myeloma
referred pain

Question 19

Can spondylolisthesis occur in older people?

Answer 19

a degenerative spondylolisthesis may occur in older people with lumbar spondylosis and osteoarthritis of the facet joints

Question 20

Which patients commonly get spondylolysis?

Answer 20

adults
in adolescents commonly due to repeated hyperextension, especially in sportsmen and gymnasts who complain of lower back pain

Question 21

How is spondylolysis managed?

Answer 21

mild cases settle spontaneously with activity modification
in severe cases, when the fracture is displaced, there may be spondylolisthesis
reduction and fixation may be required if this occurs

Question 22

When is an urgent neurosurgical review required in patients with back pain?

Answer 22

if any neurological deficit

Question 23

When is a spinal xray requested?

Answer 23

only if pain is associated with red flag symptoms or signs which indicate a high risk of a more serious underlying problem

Question 24

When is a spinal MRI requested?

Answer 24

preferable to CT scanning when neurological signs and symptoms are present. CT shows bony pathology better.
Specialist interpretation may be needed.

Question 25

When is a bone scan used?

Answer 25

useful in infective and malignant lesions but also positive in degenerative lesions

Question 26

When are FBC/ESR/biochemical tests used?

Answer 26

When pain is likely malignant/infectious or metabolic causes

Normal CRP and ESR distinguish mechanical back pain from polymyalgia rheumatica

Question 27

How should mechanical back pain be managed?

Answer 27

analgesia
brief rest if necessary
physiotherapy
patients should stay active within pain limits
early management prevents long term disability

Question 28

How is root entrapment managed?

Answer 28

short period of bed rest (2-3 days)
analgesia and muscle relaxants
when pain is tolerable encourage patient to mobilise and refer to physiotherapists

Question 29

When should root entrapment be referred for surgery (microdiscectomy/hemiaminectomy)?

Answer 29

if there are several neurological signs
if pain persists past 6-10 weeks
if disc is central

Question 30

What should you do if bladder or anal sphincter tone are affected?

Answer 30

refer neurosurgical emergency !!