Orthopaedics unit 2 backache and neckache - deck 1

Question 1

Most back pain is self-limiting and requires little treatment - T or F

Answer 1

True

Question 2

If you need to brush up on back anatomy then go to Anatomy 1 - Back, spine and spinal cord in Neuro week 1 notes

Question 3

What are the main tissues which make up the spine ?

Answer 3

The bones (the vertebrae), muscles, ligaments and nervous tissue (nerves and spinal cord).

Question 4

What are the non-nervous tissues (bones, muscles, ligaments) of the spine collectively called ?

Answer 4

Spondylitides

Question 5

Define what the term spondylitis means

Answer 5

Abnormalities/ disease in the spondylitides (bones & joints, muscles, or ligaments) of the spine resulting in pain

Question 6

Are abnormalities common in the nervous tissue of the spine ?

Answer 6

No they are very uncommon

Question 7

What are the 3 main ways in which pain may be experienced due to disorders of the spine ?

Answer 7

1. Locally (at the site of an injury/abnormality)
2. In another part of the body (referred pain)
3. Along the length of the nerve arising from an affected nerve root.

Question 8

Can backpain often be localised to a specific area (local pain) ?

Answer 8

• No people often find it difficult to pin-point the backpain
• Pain tends to be related to a whole region, such as the lumbar or dorsal regions, and it is relatively unusual for it to be located more specifically.

Question 9

Define what is meant by the term referred pain in the back and how it can present

Answer 9

Referred pain is pain felt in a part of the body other than its actual source

e.g. Pain occuring in the back may be “referred” from the back to the buttock, thigh and leg but always above the knee

Question 10

What foramina which is surrounded by the facet joints posteriorly and intervertebral discs anteriorly do nerve roots emerge from the vertebrae ?

Answer 10

Vertebral foramina (intervertebral foramina)

Question 11

Appreciate that Diseases affecting the facet joints and the discs may cause direct pressure on, or inflammatory reactions and swelling of, the nerve roots due to the close anatomical location of nerve roots and these structures

Question 12

Describe what happens in nerve root pain

Answer 12

This is when diseases affect the nerve root resulting in pain felt in the areas supplied by the spinal nerve supplied by that particular nerve root (neuralgic burning or severe tingling pain)

• Loss of sensation or muscle weakness. Such features are referred to as “localising signs”

Question 13

Define what sciatic is

Answer 13

Pain in the leg, mainly down the back of the leg but almost always into the foot caused by compression of a spinal nerve root in the lower back

Question 14

What action may exacerbate pain experienced from sciatica?

Answer 14

Coughing

Question 15

Along with the lumbar region of the spine what other region of the spine is commonly affected resulting in nerve root pain and describe its presentation

Answer 15

• The cervical region of the spine the mid to lower foramina are commonly affected
• Resulting in hand and forearm pain, often associated with tingling is characteristic.

Can also get other localising signs - loss of sensation and muscle weakness

Question 16

In this module the common causes of backache and neckpain are grouped into 2 categories:

1. Related to the spondylitides
2. Related to the nervous tissue

Under each of the 2 categories list the common conditions we should know about

Answer 16

1. Related to the spondylitides - Aches and sprains, Mechanical back pain, Spondylolisthesis.
2. Related to the nervous tissue - Disc prolapse, Bony root entrapment.

Question 17

What are the most common movements which can result in back pain and what class of back injury are these usually ?

Answer 17

• Awkward twisting, or poor lifting, causing muscle or ligament injuries.
• These type of injuries are classed as muscle strains

Question 18

When lifting a heavy object what can be done to reduce spinal loading ?

Answer 18

Reducing the distance between the back and the weight - as it results in less leverage (discussed in mechanics/biomechanics)

Question 19

How can muscle strains be distinguished from back pain which has a neurological cause e.g. nerve root entrapment ?

Answer 19

Because there is no neurological symptoms e.g. loss of sensation, muscle weakness, reduced reflexes

Question 20

Describe the management of muscle strains

Answer 20

These injuries require a brief period of rest followed by a gradual return to normal activities.

Anti-inflammatory drugs are said to help relieve symptoms, although simple analgesia is usually sufficient

Question 21

What is mechanical back pain ?

Answer 21

This can be thought of as recurrent relapsing and remitting back pain with no neurological symptoms.

Question 22

What are the 2 main possible causes of mechanical back pain ?

Answer 22

1. Spondylosis
2. Primary OA - the facet joints are likely to be as prone to primary OA as any other synovial joint.

Note tho that a definite cause is not known these are possible causes, and there are probably lots of other causes to do with muscles and ligaments

Question 23

Define what spondylosis is

Answer 23

This is when there is degeneration of the intervertebral disc leading to increased loading of the facet joints, which then develop secondary OA

Question 24

Does anything make the pain better or worse in mechanical back pain ?

Answer 24

Yes - The pain is worse with movement (mechanical) and relieved by rest

Question 25

What is the typical age range of people who experience mechanical back pain ?

Answer 25

20-60

Question 26

Describe the management for mechanical back pain

Answer 26

There is no cure so treatment involves analgesia and physiotherapy.

Most learn to live with it, patients should be reassured that they do not have a serious problem and should be urged to maintain normal function and return to work early.

Support should be provided by there GP assisted by physios and orthopaedic specialists

Question 27

For mechanical back pain what alternative medical practitioners may provide some help in treating the condition?

Answer 27

Osteopaths and chiropractors can provide some easing of the condition by manipulation.

Question 28

What is Spondylolisthesis?

Answer 28

Spondylolisthesis is the slippage of one vertebra relative to the one below, most commonly in the lower back (lumbar spine).

Question 29

What is the cause of Spondylolisthesis?

Answer 29

It is caused by a bony abnormality which interferes with the stability of the facet joints and their associated bony and ligamentous elements - spondylolysis

Question 30

What is spondylolysis ?

Answer 30

Spondylolysis is defined as a defect or stress fracture in the pars interarticularis without the forward slipping of the vertebrae

Question 31

Describe the aetiology of spondylolyisthesis may be developed

Answer 31

It may be congenital or acquired ==> can occur at any age

Adult forms of this condition are thought to be acquired, although some may be mild congenital abnormalities which have gone unnoticed previously. It appears to be acquired following an acute or, more likely, a fatigue fracture of the pars interarticularis

Question 32

Describe the clinical presentation of spondylolisthesis

Answer 32

• Someone with this condition experiences low back pain, which is almost identical to mechanical back pain.
• The condition very rarely causes neurological problems, even when the slippage is major.

Question 33

In the rare case of congenital spondylolisthesis can nerve damage occur ?

Answer 33

Yes as the slippage may be sufficient enough to damage nerve tissues

Question 34

How is spondylolisthesis usually diagnosed ?

Answer 34

Via X-ray

It can sometimes be detected on examination if severe enough slippage a step may be felt at the affected area

Question 35

How is spondylolisthesis treated ?

Answer 35

A spinal corset may help to relieve pain, otherwise management strategies are similar to those for the mechanical back pain sufferer - physio, rest and analgesia

Most sufferers do not require surgery unless they are experiencing severe pain, when spinal fusion of the two affected vertebrae may be required.

Question 36

Spondylolysis can exist without causing pain, bur if pain is experienced what is the management of it ?

Answer 36

Conservative measures are usually successful, but if the pain is severe, spinal fusion may be required

Question 37

Why is it important to put to rest (allay) the common view of the general population that most back and leg pain is caused by a ‘slipped disc’

Answer 37

Because the intervertebral disc does not “slip”, the disc contents prolapse, and in fact this is a relatively rare condition.

Question 38

What are the 2 main regions of the spine that disc prolapse may occur ?

Answer 38

The cervical and lumbar regions

Question 39

Who do disc prolapses more commonly occur in ?

Answer 39

Men and young people

Question 40

Describe the clinical presentation of disc prolpase in the lumbar region ?

Answer 40

• Classically acute backache and legache, or sometimes legache alone with backache developing later.
• The characteristic symptom is of legache passing down the back of the thigh and leg to the foot, unlike in regular backache. Can have the numbness and weakness and reduced sensation also. This explains why prolapsed discs are often called sciatica

Unlike referred backache which goes no further than the knee

Question 41

Describe the history of how disc prolapses occur ?

Answer 41

They may occur a single event of lifting or strain e.g. lifting a heavy object which results in acute disc tear and ==> can result in a disc prolapse due to the tear

Or they may occur spontaneously

Question 42

What is the underlying cause of a disc prolapse ?

Answer 42

an abnormality in the intervertebral disc, which leads to prolapse (extrusion) of the nucleus pulposus material through the annulus fibrosis

Question 43

If a disc prolapses posteriorly and laterally what structure can become impinged and if this occurs in the lumbar region how would the patient present ?

Answer 43

The nerve root

patients complain of shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected hence prolapsed discs can often be called sciatica

Question 44

What part of the lumbar region of the spine is most commonly affected by disc prolapses ?

Answer 44

The discs between the sacrum and the fifth lumbar vertebra are most commonly affected

Question 45

What nerve roots are commonly compressed by disc prolapses in the lumbar region and why is this relevant to why prolapsed discs are often called sciatica ?

Answer 45

Nerve roots L4,5 & S1

The brain interprets pressure on a nerve root as occurring in the peripheral nerve arising from it, and since all the nerve roots above contribute to formation of the sciatic nerve this is why it often presents as sciatica

Question 46

What is meant by the term localising signs ?

Answer 46

When the pattern of symptoms is so specific, clinicians talk of the clinical examination revealing localising signs.

Question 47

If a prolapsed disc protrudes posteriorly what structures may be compressed ?

Answer 47

Spinal cord or more commonly caudia equina

Question 48

Describe the management of prolapsed discs

Answer 48

It is essential to make sure that nerves supplying the bladder and bowel are not damaged.

Once this is confirmed a combination of rest and gentle, progressive mobilisation. Analgesics and anti-inflammatory drugs may help to relieve symptoms.

If pain persists or localising signs get more severe then surgical intervention to remove the disc material is required - disectomy

Question 49

Why do most prolapsed discs recover spontaneously ?

Answer 49

Because the disc material is absorbed by cells from the bloodstream

Question 50

Before undertaking a disectomy for a prolapsed disc what needs to be done ?

Answer 50

The site of the disc prolapse is confirmed by injecting a radio-opaque material into the spinal fluid and then taking an X-ray

Such a technique is called myelography and the “picture” which results from it is called a myelogram.