Pain, Common Conditions (Session 1) Flashcards
Definition of “Pain”
An unpleasant or sensory or emotional experience associated with or resembling, actual or potential tissue damage.
Acute Pain
Nociceptive:
- Localised tissue damage
- Generally less than 3-6 months.
- Normal physiological response to noxious stimulus.
- Modified by fear, anxiety and previous experience.
Chronic Pain
Nociplastic:
- Last beyond normal healing time after injury
- Widespread pain (hyperalgesia / allodynia)
- Results from neuroplastic changes to pain pathways: peripheral & central sensitisation, descending facilitation and dishinibition.
Neuropathic Pain
- Lesion or disease affecting somatosensory system.
- Central or peripheral, such as radicular pain from an injured nerve.
- Burning, shooting, or pricking.
- Sensory and/or motor deficits
Mechanisms of “Nociceptive” pain
- Localised pain, not widespread.
- Proportionate to injury
Mechanisms of “Nociplastic” pain (Central Sensitisation)
- Widespread or diffuse pain
- Disproportionate to injury
- Hyperalgesia & Allodynia
Types of referred pain
- Radicular Pain (Neuropathic)
- Referred somatic pain (Nociceptive)
- Referred visceral pain
(Nociceptive)
Referred somatic pain
Produced by noxious stimulation of nerve endings within spinal structures such as discs, zygapophysial joints, or sacroiliac joints.
Radicular Pain
Pain created by ectopic discharges arising from a dorsal root or its ganglion.
- Inflammation of the affected nerve (not compression).
- Pain is lancinating (sharp), shocking, or electric in a narrow band like distribution down the leg.
Common Lumbar Spine Conditions
- Nonspecific LBP (‘mechanical’)
- Degenerative joint disease
- Intervertebral disc disease
- Spondylosis, spondylolisthesis
- Congenital anomalies
- Inflammatory arthritis
- Visceral referral
Uncommon Lumbar Spine Conditions
- Malignancy
- Infection
- Paget’s Disease
- Diffuse idiopathic skeletal hyperostosis
Non-specific LBP (NSLBP)
‘NSBLP’ is used when the pathoanatomical cause of the pain cannot be determined:
- 90% of uncomplicated LBP
- Clincal tests cannot definitively identify the source of pain
- Can be acute or chronic
Degenerative Joint Disease (DJD)
Synonymous with (OA)
Chronic degenerative condition of lumbar spine that affects, vertebral bodies, intervertebral discs, facet joints and contents of spinal canal.
DJD occurs to a majority of what people?
To an extent, everybody as part of ageing degeneration.
> 90% of those are 50 years or over.
Typical presentation of DJD
- Older age group
- Gradual onset / chronic condition
- Aching pain
- Spinal tenderness
- Stiffness
- Aggravated by over use
- Stiffness after periods of inactivity
- Pain reduced by paracetamol
Risk factors of DJD
- Heavy, physical work
- Excess weight
- Previous low back injury
- Early onset can be familial
Diagnosis of DJD
- History
- Physical examination
- X-ray
Stenosis
“narrowing”
Lateral Canal Stenosis (LCS)
Narrowing of intervertebral foramen
Causes of Later Canal Stenosis
- DJD
- Disc protrusion of prolapse
Conditions of Lateral Canal Stenosis
- Can be asymptomatic
- Usually unilateral
- Nerve root and / or spinal nerve impact
= Radicular Pain (lancinating, shocking, electric pain)
= Radiculopathy (loss of function myotomes, dermatomes, reflexes
Central Canal (Spinal) Stenosis (CCS)
Narrowing of the spinal canal
Causes of Central Canal Stenosis
- DJD
- Disc protrusion or prolapse
- Congenital
- Spondylolisthesis
Conditions of Central Canal Stenosis
- Can be asymptomatic
- May impact spinal cord / cauda equina
= Neurogenic Claudication: (pain, paraesthesia, cramping, heavy legs (one or both) on walking (relieved by flexion)
= Cauda Equina Syndrome: LBP, lower limb pain/weakness, perineal paraesthesia, bowel/bladder disturbance
Cauda Equina Syndrome requires?
Immediate medical/surgical referral.
Most often due to IVD
Conditions of Cauda Equina Syndrome
- Back pain and/or unilateral/bilateral leg symptoms
- Reduced perineal sensation
- Altered bladder function
- Loss of anal tone
- Loss of sexual function
Intervertebral Disc Disease
- Degenerative
- Prolapse & hernitation
- Internal disc disruption
Degenerative Disc Disease
Disc becomes less hydrated and thinner with age, lose capacity for shock absorption and become susceptible to tears in the pain sensitive outer annulus.
- Normal part of ageing
- Often asymptomatic
- Diagnosis by MRI
- Cause pain in middle age (30-50yrs)
Intervertebral Disc Prolapse
- Protrusion or budge (posteriorly)
- Prolapse (nucleus contained)
- Extrusion (annulus fibrous disrupted)
- Sequestration (Free nuclear material)
Mechanism of Intervertebral Disc Prolapse Injury
- Repetitive mechanical twists such as bending and twisting (no breaks)
- Fully flexed spine for repeated or long time (under load)
- Forceful rotation
- Heavy lifting
Presentation of Intervertebral Disc Prolapse
- Young to middle age (20-50yrs)
- Rare in children or elderly
- Male to female 2:1
- Typically occurs suddenly but can develop gradually over weeks
Symptom presentation of lumbar disc prolapse
Common:
- Severe, actue LBP
- Antalgic posture
- Paraspinal muscle spasm/gaurding
- Radiating pain in lower limb (Radicular pain)
- Lower limb paraesthesia (Radiculopathy)
Aggravation of lumbar disc prolapse
Flexion:
- Sitting
- Bending
Bearing Down:
- Sneezing
- Toilet
Relief of lumbar disc prolapse
Lying down
Internal Disc Disruption
Condition which internal architecture of disc is disrupted but external surface remains normal.
Grades of Internal Disc Disruption
Grade 1: Disruption of inner third annulus fibrosus.
Grade 2: Disruption of inner two-thirds of annulus.
Grade 3: Disruption of outer third of annulus (pain sensation area)
Grade 4: Grade 3 fissure spreads around between lamellae of outer annulus.
Symptoms of internal disc disrutpion
- Constant deep aching pain
- Aggravated by any movement that stresses disc (mechanical LBP)
(Cannot be diagnosed clinically)
Spondylolysis
Defect or stress fracture in pars interarticularis of vertebral arch
Spondylolysis results from
- Repetitive mechanical load/stress
Spondylolysis occurs in who
Young athletic population (cricket, tennis, gymnast)
- Male to female 2:1
Spondylolysis effects what percentage of population?
3-6% of the population
Symptoms of spondylolysis
- Focal LBP with buttock pain.
Aggravated:
- Extension & Rotation
- Hyperlordosis
Relief:
- Rest
Spondylolisthesis
The slippage of one vertebra on the next, causing pain and/or radicular symptoms
Spondylolisthesis frequently occurs in which spinal levels
Frequently L5/S1
- If severe can produce canal stenosis (rare)
Presentation of spondylolisthesis
- Intermittent, localised LBP
- Agg. by flexion/extension
- Pain on palpation
- Step-off sign
- Relieved lying supine
- Hamstring tension/discomfort
Spondylolisthesis is diagnosed by what?
X-Ray
Types of Congenital Anomalies
- Spina bifida occulta
- Facet Tropism
- Transitional Vertebrae
= Lumbarisation
= Sacralisation
Spina Bifida Occulta
Asymptomatic non-union of the posterior vertebral elements (no spinal cord impact)
Observation of spina bifida occulta
- Hairy patch
- Dimple in back
- Fatty deposits
- Port wine mark
Facet Tropism
Asymmetry in the sagittal orientation of the facet joints.
- May be associated with instability and degeneration
Lumbarisation
S1 is not fully fused with sacrum (appears as 6 lumbar vertebras)
Sacralisation
L5 is fully or partially fused to the base of sacrum
(can appear as 4 lumbars)
Ankylosing Spondylitis
Form of inflammatory arthritis. Predominately effects the spine by creating inflammation of joints.
Ankylosing Spondylitis affects what percentage of population?
About 1% percent of population
- Male to female 2:1
What age group do Ankylosing Spondylitis symptoms onset ?
20-40 y.o.
(<5% >45% y.o.)
Typical presentations of Ankylosing Spondylitis
- Low back/buttock/SI pain is often the first symptom
- Insidious onset
- Spinal stiffness (loss of ROM)
- Morning stiffness (>30min)
- Chronic in nature
- Relieved by activity
- Aggravated by rest
Diagnosis of Ankylosing Spondylitis
- Clinical presentations
- Blood Tests
- Xray
What are uncommon causes of LBP?
- Osteomyelitis (bone infection)
- Malignancy (cancer)
- Paget’s Disease (Metabolic disease causing abnormal bone formation)
Diffuse Idiopathic skeletal hyperostosis (DISH)
