Neck and Back Pain Flashcards
what are the differentials for neck pain
Trauma
Mechanical Pain
Brachial neuralgia/Cervical Root pathology
Cervical Spondylosis
Cervical Myelopathy
Ankylosing Spondylitis
what kind of forces commonly cause neck pain
acceleration/deceleration forces e.g. car crash
how does whiplash present
pain in neck/shoulder
dizziness
headache
memory loss
how long does it take whiplash to settle
months
how does a cervical radiulopathy present
‘aching pains’ down arm
Progressive loss of pinch grip
Dermatomal sensory loss
May be occasional shooting pains down the arm – reproducible with spurlings test (turn patients head to affected side and presses down on the top of the head (as if you’re trying to compress the spine vertically))
what is the most common cause of cervical radiculopathy in the older population
osteophytes
what is found on examination for cervical radiculopathies
UMN signs below the level of compression
LMN signs at the level of compression
For example a C5/6 lesion leads to wasting and fasciculation of the deltoids + biceps with hyporeflexia, but hyperreflexive triceps and spastic legs with upgoing plantars
+ve Hoffmans sign
Abrupt force on the middle fingernail (e.g. flicking it) causes flexion in the thumb/index finger
UMN sign
Positive Spurlings test
what are differential causes for cervical radiculopathy
osteophytes
Cervical Malignancy
Disc Degeneration
what are life threatening causes of back pain that must be ruled out
AAA
Aortic Dissection
Pancreatiits
MI
what are red flags for back pain
<20, >55
Constant or progressive pain
Night pains
B symptoms
Bladder/bowel symptoms
History of TB/HIV/malignancy
Thoracic spine pain
History of significant trauma
Saddle anaesthesia
Point tenderness in midline
what are features of simple mechanical back pain
Usually lumbosacral region
20-55 years old
Normally a fixed point in which the pain started, usually with some form of bending with a load, twisting etc
Buttock/thigh pain may be referred
Palpable muscle spasm on exam
Diagnosis of exclusion
whats the management of mechanical back pain
Analgesia
Keep active
Physio exercises
whats the prognosis of simple mechanical back pain
90% recover within 6 weeks
what age ranges most commonly get lumbar disc prolapse
30-50
what region commonly is affected for lumbar disc prolapse
L4/5, L5/S1
when does a herniated disc cause cauda equina syndrome
if the herniation is central
what are some features of cauda equina syndrome
Triggering event leads to patient seizing up + unable to straighten back
Pain worse on coughing/straining
Pain moves into buttock within hours and into the leg within a day or 2
Radicular pain also present
Severe lancinating (stabbing) pains/paraesthesia in one leg
Rarely in both
Associated clumsiness of the foot
Associated bladder/bowel problems
Incontinence
Retention
what intervention is required in cauda equina syndrome
Emergency MRI/urgent surgical intervention required to prevent long term bladder/bowel/reproductive sequele
what may you find on examination in cauda equina syndrome
Patient may walk with a flexed leg or with obvious scoliosis
On spinal examination there may be scoliosis and palpable muscle spasms
Straight leg raise to 30 degrees produces pain
Contralateral also causing pain = bad sign, indicates a very large lesion
Pain in anterior thigh on femoral stretch test also suggests upper disc prolapse
Neurological exam shows muscle weakness, loss of sensation and diminished reflexes at the affected level
what focal signs are prominent on cauda equina at L4
Muscle weakness, loss of sensation and diminished reflexes at the affected level
Most commonly extensor hallucis longis and tibialis anterior, extension of big to, dorsiflexion of foot
what focal signs are prominent on cauda equina at L5
muscle weakness, loss of sensation and diminished reflexes at the affected level
Peroneus brevis and longus may also be affected along with foot eversion
what focal signs are prominent on cauda equina at S1/2
muscle weakness, loss of sensation and diminished reflexes at the affected level
Gastrocnemius and soleus are affected in lower lesions along with plantar flexion
what examinations are required if you think cauda equina syndrome is happening
PR – no sensation/anal tone
Palpate bladder for retention
Retention will be painless
Check sensation of saddle area
whats the management of suspected disc herniation
Conservative management
NSAIDS
Bed rest with knee slightly flexed
Reduces herniation in more than 90%
Symptoms >2 weeks Regular epidural injections to treat radiculopathy MRI/surgical referral Single level disease = microdiscectomy Removal of herniating material Rehab essential
what are common causes of lumbar canal stenosis
OA
Disc degeneration
Facet joint hypertrophy
Ligamentum flavum hypertrophy
what are some symptoms of lumbar canal stenosis
Aching pains in legs when walking
Pain recovers on sitting/bending forwards
Numbness/weakness/stiffness in legs
Symptoms variable
whats the management of lumbar canal stenosis
Conservative
Activity modification
Physio
Surgical
Laminectomy
OA-related pain remains
what is spondylolithesis
one vertebra is displaced on the vertebra below, anteriorly or posteriorly
what vertebrae is usually affected in spondylolithesis
L4/5 or L5/S1
what is the presentation of spondylolithesis
Intermittent backache
Worse with activity
what do you expect to find on examination in spondylolisthesis
a step on spinal examination
what are common causes of spondylolithesis
most commonly - stress fracture on the lumbar pars articularis
dysplasia of lumbar facet joints
OA of facet joints
what are risk factors for OA of facet joints
old age
extreme athletes
whats the management for spondylolithesis
Conservatively, as for mechanical back pain
If symptoms are severe or patient is young, spinal fusion can be performed
what are common causes of non-mechanical back pain
Inflammatory
Infective - discitis
Metabolic - osteoporosis , pagets, hyperparathyroidism
Neoplastic - mets, myeloma
what are some features of facet joint dysfunction
Highly common cause of lower back pain
OA/RA may be cause, but commonly its minor trauma
Leading to acute or chronic back pain, worse on standing, extension of the back or in the morning
No history of pain In the legs
May be local tenderness over facets
