Neck and Back Pain Flashcards
What are the main causes of back pain?
MSK:
- Simple mechanical back pain (90%)
- Destructive (infection/metastasis)
- Fracture (traumatic or pathological)
- Spondilitis (inflammation of the spine)
- Metabolic (OP/ Padgets/ HPThyriod)
- Lumbar stenosis
- Disc prolapse
Other systems:
- Aortic dissection
- MI
- Pancreatitis
- Peptic ulcer disease
Describe the classical features of mechanical back pain?
General hx:
- Occurs most commonly in patients 20-55yo
- No systemic features or red flags
Pain hx:
- Precipitated by lifting or bending
- Realtively sudden onset pain
- Quite severe
- Usually in the lumbar or cervical region
- Tender over the paraspinous muscles
Caused by muscle/ligamentous strains with resoloution within a few weeks with no intervention needed.
What are the red flag symptoms in back pain?
Cancer/ Infection
- Age less than 20 or greater than 50
- Constitutional symptoms (weight loss, night sweats)
- History of malignancy/Tb
- Night pain
- Immunosuppression or IV drug abuse
- Systemic symptoms: fever, chills shakes
Inflammatory disease
- Early morning stiffness >60 mins
- Global reduction in movement
- Pain worse after rest
- Extra articular features (rash, uveitis, bowels, fingers, enthesis)
Metabolic disease
- History of trauma
- Pain related to lying
- Kyphosis
Neurological:
- Saddle anaesthesia
- Progressive neurological symptoms (bladder or bowel dysfunction)
Visceral
- Symtoms of AAA, pancreatis etc
Describe the imaging modalities which can be used to further investigate a patient with red flag symptoms?
Xray: will show fractures (metabolic), late lytic or sclerotic lesions (mets) and obvious bony abnormalaties e.g. bamboo spine, spondylolisthesis (Inflammatory e.g. AS), metabolic abnormalities (OP, padgets)
MRI: should be done if ?: cauda equina, lumbar stenosis, disc prolapse if not recovering, cancer
Can CT in spondylolisthesis, or if query visceral cause
What is Spondylolisthesis?
When one vertebra slips either anteriorly or posteriorly on the vertebra below it. (anterolisthesis or posterolisthesis)
What is Spondylosis?
Degeneration over the vertebral column (OA of the spine).
Speifically it is facet (apophyseal) joint OA and disk degeneration*.
Note: spondylitis is inflammation of the spine
*Disk degeneration is different to prolapse as it is not herniation of the nucleus pulposis it is the disk losing water and becoming flattened and thickened.
What are the causes of back pain radiating into the leg?
Anything which causes nn root compression
- Prolapsed disk (most common cause) usuallt in L4/L5 or L5/S1
- Spondylolisthesis
- Malignancy
- Mechanical back pain
What are the symptoms of spondylolisthesis?
- Lower back pain which worsens on bending forward.
- May radiate into the legs.
- May cause paraesthesiae.
What are the symptoms associated with Spondylosis?
Symptoms: (OA OF SPINE)
- Spinal joint pain or tenderness that intermittently return.
- Stiffness particularly early morning.
- Osteophyte formation on Xray.
- Painful movement of affected area.
- If osteophytes cause nn root compression can cause radicular symptoms. e.g. cervical radiculopathy
- What is spinal canal stenosis?
- What causes it?
- What can it cause?
- It is narrowing of the spinal canal
- prolapsed disks, spondylosis (OA), ligamentum flavum thickenning, spondylitis (AS), spinal tumours, trauma, padgets, scoliosis, spondylolisthesis
3.
- Cervical myelopathy this usually occurs if the compression has been over a prolonged course.
- Neuropathic claudication if in the lumbar spine
- Cauda equina
- Radiculopathy
What are the symptoms of cervical myelopathy?
Presentation is very varied and you can get a mixed lower and motor neurone signs:
- LMN at the point of the lesion caused by compression of the nn root or the nn root synapse within the cord.
- UMN signs below the lesion due to compression of the cord. Therefore predominantly it is upper motor neuron.
- If there is no nn root compression of root synapse compression then there will only be UMN signs.
The classical presentation:
- Loss of balance (ataxic broad based gait)
- Poor coordination,
- Decreased finger dexterity,
- Weakness (often affects upper limb more)
- Numbness
- Can cause paralysis in severe cases
- Hoffmans sign (flick middle finger, thumb flexes)
How is cervical myelopathy managed?
Condition almost always is progressive. MRI spine is manadatory and refferal to spinal clinic. Treatment options include:
- If patient is young and it is caused by cervical disk prolapse then can perform cervical disk replacement.
- In patients with advanced spondylitic changes who are fit for surgery decompression with fusion is performed.
- If unfit for surgery then supportive management with analgesia and OT input.
How is disk prolapse managed?
Conservative:
- It is often self limiting however it may last from weeks to months, which may not be acceptable for some patients.
- No clear consensus of when to perform surgery
Surgery:
- In single level disease a simple discetomy is performed.
- In multi level disease a laminectomy is performed (removalof the posterior bony wall aka the lamina creates more space)
How is mechanical back pain managed?
Adequate analgesia and advised to remain as mobile as possible.
NSAIDs +/- PPI, Codeine
In recurrent cases referral for physiotherapy may be beneficial.
Spondylolisthesis commonly conservatively managed in much the same way as mechanical back pain.
Which conditions can cause inflammatory spondylitis?
AS, Psoriatic arthritis, Reiters syndrome, IBS
