Neck and back pain 2 Flashcards
What is lumbar disc prolapse?
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
How does lumbar disc prolapse present?
starts during lifting, twisting or bending lower back pain radiating to the buttock muscle spasm severe lancinating pains parathesia and numbness in one leg
What would be seen on examination in lumbar disc prolapse?
scoliosis and muscle spasm
positive straight leg raise test
cauda equina - perianal sensory loss
positive femoral stretch test suggests upper lumbar disc prolapse
What is spinal and root canal stenosis?
caused by progressive loss of disc height, osteoarthritis of facet joints, posterolateral osteophytes and hypertrophy of ligamentum flavam
How does nerve root pain or spinal root claudication present?
pain and paraesthesia in a root distribution brought on by walking and relieved slowly by rest
What differentiates spinal root claudication from arterial claudication?
slow recovery when the patient rests and presence of normal foot pulses
What are the symptoms of spinal canal stenosis?
bilateral leg and buttock pain
paraesthesia and numbness when walking
rest and bending forwards helps
What is spondylosis/spondylolisthesis?
occurs in adolescents and young adults due to the pars interarticularis defects causing instability and permit the vertebra to slip +/- preceding injury
What are the risks associated with spondylosis/spondylolisthesis?
cauda equina syndrome with loss of bladder and bowel function
needs careful monitoring during the growth spurt
What is disseminated idiopathic skeletal hyperostosis?
bony overgrowths and ligamentous ossification affecting the spine and extraspinal locations
extensive xray changes
patients have a stiff back that isn’t always painful
How does inflammatory back pain present?
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
What other conditions are associated with inflammatory back pain?
anterior uveitis psoriasis IBD Erythema nodosum Enthesopathy Juvenille oligoarticular problem
What are the causes of inflammatory back pain?
infective lesions of the spine
ankylosing spondylitis/sacroiliitis
What are the causes of metabolic back pain?
osteoporotic spinal fractures
osteomalacia
paget’s disease
What are the causes of osteoporotic spinal fractures?
develop without trauma, after minimal trauma, or as part of a major accident
How do osteoporotic spinal fractures present?
can be asymptomatic
may cause agonising localised pain, radiating around the ribs and abdomen
How does neoplastic back pain present?
bony pain over a single spinal segment night pain progressive unrelated to movement no relieving or exacerbating factors can't be reproduced on examination
What are the causes of neoplastic back pain?
metastases
primary tumours
multiple myeloma
referred pain
Can spondylolisthesis occur in older people?
a degenerative spondylolisthesis may occur in older people with lumbar spondylosis and osteoarthritis of the facet joints
Which patients commonly get spondylolysis?
adults
in adolescents commonly due to repeated hyperextension, especially in sportsmen and gymnasts who complain of lower back pain
How is spondylolysis managed?
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
When is an urgent neurosurgical review required in patients with back pain?
if any neurological deficit
When is a spinal xray requested?
only if pain is associated with red flag symptoms or signs which indicate a high risk of a more serious underlying problem
When is a spinal MRI requested?
preferable to CT scanning when neurological signs and symptoms are present. CT shows bony pathology better.
Specialist interpretation may be needed.
When is a bone scan used?
useful in infective and malignant lesions but also positive in degenerative lesions
When are FBC/ESR/biochemical tests used?
When pain is likely malignant/infectious or metabolic causes
Normal CRP and ESR distinguish mechanical back pain from polymyalgia rheumatica
How should mechanical back pain be managed?
analgesia
brief rest if necessary
physiotherapy
patients should stay active within pain limits
early management prevents long term disability
How is root entrapment managed?
short period of bed rest (2-3 days)
analgesia and muscle relaxants
when pain is tolerable encourage patient to mobilise and refer to physiotherapists
When should root entrapment be referred for surgery (microdiscectomy/hemiaminectomy)?
if there are several neurological signs
if pain persists past 6-10 weeks
if disc is central
What should you do if bladder or anal sphincter tone are affected?
refer neurosurgical emergency !!
