Neck & Back Pain Flashcards
What is the differential diagnosis for neck pain?
Trauma (inc. whiplash) Mechanical neck pain Cervical spondylosis Cervical myelopathy Ankylosing spondylitis Fibromyalgia
What is a whiplash injury?
Injury caused by acc-decc forces applied to the neck
What causes a whiplash injury?
Acc-decc forces
Typically RTA w/ pt wearing seatbelt, struck from behind
How does a whiplash injury present?
Pain in neck/shoulder/arm
Headache
Dizziness
Memory loss
How is whiplash injury managed?
Symptomatic management
Can take months to settle
Radiology only indicated if ?bone injury
What causes mechanical neck pain?
Post injury
Falling asleep in awkward positions
Prolonged keyboard working
How does mechanical neck pain present?
Pain -associated w/ palpable muscle spasm -can radiate up to occiput Tension headache Associated w/ fibromyalgia
What causes Cervical Radiculopathy/Brachial Neuralgia?
Compression of cervical neck roots
- typically osteophytes in older populations
- acute cervical disc prolapse following minor trauma
How does Cervical Radiculopathy present?
Aching pain in neck, going down arm
-sudden sharp pains down arm
Progression to mild loss of pinch grip strength
Dermatomal sensory loss
What is Spurling’s test?
Recreates sudden pain of Cervical Radiculopathy
- turns pts head to affected side
- extends & applies downward pressure to top of head
What investigations are appropriate in suspected Cervical Radiculopathy?
XR/MRI
Refer to neurosurgery
What causes Cervical Myelopathy?
Compression of cervical spinal cord
- osteophytes
- cervical disc degeneration
- malignancy
How does Cervical Myelopathy present?
Older pts
Problems w/ fine motor control in hands
Slowly developing spastic gait
Pain NOT predominant feature
What are the signs on examination of Cervical Myelopathy?
UMN signs below level of compression
LMN signs at level of compression
Hoffman’s +ve
What is Hoffman’s sign?
Sign of UMN disease
-flicking distal phalanx leads to flexion of other fingers
What investigations are appropraite in suspected Cervical Myelopathy?
XR/MRI
Ref to neurosurgery
What life threatening visceral pathology should be ruled out when investigating back pain?
AAA
MI
Pancreatitis
What is the most common cause of back pain?
Simple mechanical back pain (90%)
-resolves spontaneously
What are the red flag sx present in back pain that indicate severe pathology?
Age <20 or >55 Constant/progressive pain (e.g. at night) B sx Bladder/bowel sx History of TB/HIV/Malignancy Pain in thoracic spine Hx of significant trauma
What are the red flag signs present in back pain that indicate severe pathology?
Saddle anaesthesia (cauda equina) Point midline tenderness on palpation (malignancy)
How does simple mechanical back pain present?
20-55yr old Pain -came on suddenly when lifting -varies w/ physical activity/posture/time -referred to buttocks/thighs
What are the signs on examination of simple mechanical back pain?
Palpable muscular spasm
-causes local pain/tenderness
When can a diagnosis of simple mechanical back pain be made?
When clinician is satisfied there is no specific cause for the pain
How is simple mechanical back pain be managed?
Simple analgesia
Advice to keep active w/ normal activities
Physiotherapy exercises
What is the prognosis of simple mechanical back pain?
90% recover w/i 6wks
-re-assess if not resolved
What causes Acute Lumbar Disc Prolapse & Nerve Entrapment?
Nucleus pulposus of disc herniates into spinal canal
-precipitated by lifting/sneeze
Where does Acute Lumbar Disc Prolapse & Nerve Entrapment most commonly occur?
L4/L5 OR L5/S1
How does Acute Lumbar Disc Prolapse & Nerve Entrapment present?
2nd-4th decade Triggering event known after which pt is seized up w/ pain & unable to straighten up -worse on coughing/straining -move into buttock w/i hrs, into leg w/i 1/2 days Radicular pain Bladder/bowel sx Cauda equina syndrome Self-limiting lower back pain
What is radicular pain?
Severe lancinating pains & paraesthesia/numbness in one leg due to compression of sciatic nerve root
- can rarely affect both legs
- associated clumsiness of foot
What are the signs on examination of Acute Lumbar Disc Prolapse & Nerve Entrapment?
Pt may walk w/ flexed leg/obvious scoliosis Palpable muscle spasm Straight leg raised to 30o causes pain -if +ve w/ contralateral leg suggests large lesion Femoral stretch test +ve Muscle weakness Loss of sensation Diminished reflexes
What are the muscles most commonly affected by Acute Lumbar Disc Prolapse & Nerve Entrapment?
Extensor hallicus longus & tibialis ant
-L4 (extension toe, dorsiflexion foot)
Peroneus longus/brevic
-L5 (foot eversion)
Gastrocnemius/soleus
-S1/2 (plantar flexion)
What is the femoral stretch test?
Screens for nerve root impingements -pt lies prone -knee passively flexed to thigh -hip passively extended Positive if pain experienced
What examinations must always be performed to rule out cauda equina?
PR (no sensation, loss of anal tone)
Bladder palpation (signs of retention)
Check sensation of saddle area
What investigations may be appropriate in suspected Acute Lumbar Disc Prolapse & Nerve Entrapment?
Thorough hx to separate referred pain from true nerve root pain
-natural hx is relapsing/remitting episodes
What is the initial management of Acute Lumbar Disc Prolapse & Nerve Entrapment?
Anti-inflammatories & bed rest w/ knees slightly flexed
Bed rest for 2wks
-reduces herniation in >90%
What is the management of Acute Lumbar Disc Prolapse & Nerve Entrapment w/ sx persisting at 2wks?
Epidural injections (treat radicular sx)
MRI/surgical referral indicated
Microdiscectomy (single level disease)
Rehabilitation w/ physiotherapist
What is the emergency management of Cauda Equina syndrome?
Emergency MRI
Urgent surgical intervention
What causes Lumbar Canal Stenosis?
Degeneration of spine
- facet joint hypertrophy
- ligamentum flavum hypertrophy
- disc degeneration
- OA
How does Lumbar Canal Stenosis present?
Sx of spinal claudication
- aching pain in legs on walking
- pain recovers slowly on sitting/bending forwards
- numbness/stiffness/weakness
- variable day-day
What is the management of Lumbar Canal Stenosis?
Depends on stable/progressive course
Conservative - activity modification, physiotherapy
Surgical - laminectomy (OA related back pain remains)
What are facet joints responsible for?
Keeping vertebrae in AP alignment
What is Spondylolisthesis?
Condition where one vertebra is displaced either ant/post on vertebra below
- anterolisthesis
- posterolisthesis
Where does Spondylolisthesis most commonly occur?
L4/L5
L5/S1
How does Spondylolisthesis present?
Intermittent backache
Precipitated by exercise/strain
Step found on palpation
What causes Spondylolisthesis?
Spondylosis -most commonly stress fracture of lumbar pars articularis Dysplasia of lumbosacral facet joints OA of facet joints Extreme athletes
How is Spondylolisthesis managed?
Managed conservatively as per simple mechanical back pain
Spinal fusion if pt young/disabling sx
Cauda equina may develop
What causes facet joint dysfunction?
OA/RA
Minor trauma
How does facet joint dysfunction present?
Acute/chronic back pain
- worse on extension of back/in morning/on standing
- no hx of pain in legs
- localised tenderness over facets o/e
What are the four types of non-mechanical back pain?
Inflammatory
Infection
Metabolic
Neoplastic
How does inflammatory back pain present?
Insidious onset of stiffness/pain
- worse in morning
- associated w/ systemic upset
How does infective back pain present?
Localised pain/raised inflammatory markers
-post spinal surgery/injection
How is infective back pain managed?
Admission for IV a/b
What are the causes of metabolic back pain?
Osteoporotic wedge fractures Thoracic lyphosis Myeloma Paget's disease HyperPTH
How does metabolic back pain present?
Asymptomatic
Localised pain radiating around ribs
What investigations may be appropriate in metabolic back pain?
XR (wedging, loss of ant vertebral body height)
What are the causes of neoplastic back pain?
1o tumours 2o mets (most common)
What are the most common 1o sites of bony mets?
Lung Breast Kidney Prostate Thyroid
How does neoplastic back pain present?
Progressive pain
- particularly at night
- no exacerbating/relieving factors
- pain over particular bony segment
