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Head, Neck And Neuro > PBL- Back Pain Leading To Chronic Incapacity > Flashcards

PBL- Back Pain Leading To Chronic Incapacity Flashcards

1
Q

What are the red flags of lower back pain?

A 
Previous history of malignancy 
Younger than 16, older than 50 with new pain
Weight loss
Prolonged steroid use
Recent serious illness
Recent significant infection
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2
Q

List some mechanical causes of lower back pain below.

A 
Trauma
Muscular and ligament pain
Pustular back pain
Facts joint syndrome
Lumbar disk prolapse 
Lumbar spondylosis
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3
Q

Describe the anatomy of an intervertebral disk.

A

Soft gelatinous centre called nucleus pulposus, encircled by a strong, ring-like collar of fibrocartilage called the annulus fibrosis.

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4
Q

What is the main function of an intervertebral disk?

A

Shock absorption

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5
Q

What happens in an intervertebral disk prolapse?

A

Nucleus pulposus is squeezed out of place and herniated through the annulus fibrosis

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6
Q

Name some reasons an IV disk would become damaged?

A

Trauma
Effects of aging
Degenerative disorders of the spine

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7
Q

Briefly describe pathology involved once an IV disk herniation has occurred?

A

Posterior protrusion of the nucleus pulposus towards the intervertebral foramen and its contained spinal root.
Annulus fibrosis becomes thin and poorly supported by posterior or anterior ligaments at this point

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8
Q

Which regions of the spine are most commonly involved in disk herniations?

A

Cervical and lumbar

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9
Q

Where are the signs and symptoms of a disk herniations seen?

A

Localised to the area of the body innervated by the affected spinal nerve roots- includes motor and sensory

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10
Q

If the nerve roots L4, L5, S1, S2 and S3 are damaged, what condition arises?

A

Sciatica

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11
Q

Describe where the pain is felt in sciatica?

A

Spreads down the back of the leg and over the sole of the foot

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12
Q

What are the most common sensory effects from spinal root compression?

A

Paraesthesia and numbness

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13
Q

What are the most common motor effects from spinal root compression?

A

Knee and ankle reflexes may be absent or diminished

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14
Q

What are the symptoms of severe spinal disease?

A 
Pain worse at rest
Thoracic pain
Fever
General malaise 
Urinary retention
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15
Q

What signs and symptoms of cord compression occur in severe spinal disease?

A 
Back pain
Leg weakness
Limb numbers
Ataxia
Urinary retention
Hyperreflexia 
Clonus
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16
Q

What signs and symptoms of cauda equina compression occur in severe spinal disease?

A 
Bilateral leg pain
Back pain
Urinary retention 
Perinatal sensory loss
Erectile dysfunction 
Reduced anal tone
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17
Q

What are the layers of protection for the spinal cord?

A 
Vertebrae
Vertebral ligaments
Fat and connective tissue in epidural space
Meninges
 CSF
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18
Q

At what point do the spinal nerves stop being covered in meninges?

A

Once they exit the spinal column through the intervertebral foramen

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19
Q

What is the epineurium?

A

The outer covering of spinal and cranial nerves

- continuous with dura mater

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20
Q

Describe the connective tissues of the dura mater.

A

Thick, strong, dense and irregular

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21
Q

Describe the connective tissues of the arachnoid mater.

A

Thin, avascular with loosely arranged collagen and elastic fibres

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22
Q

Describe the connective tissues of the pia mater.

A

Thin and transparent
Bundles of collagen fibres and some elastic fibres
- adheres to surface of spinal cord and brain

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23
Q

Which meningeal layer contain blood vessels? (At least in the spine :/)

A

Pia mater and dura mater

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24
Q

What are denticulate ligaments?

A

Triangular shaped membranous extensions of the pia mater than suspend the spinal cord in the middle of the rural sheath

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25
Q

Where does the spinal cord arise and terminate in adults and babies?

A

Arises in the medulla oblongata
Terminates
- superior border of 2nd lumbar vertebrae in adults
- L3,4 in newborns

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26
Q

What is the superior enlargement of the spinal cord, and where does it span?

A

It’s a cervical enlargement, that nerves to and from the upper limb arise from
Spans from C4 to T1

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27
Q

What is the inferior enlargement of the spinal cord, and where does it span?

A

It’s a lumbar enlargement, that nerves to and from the lower limb arise from
Spans from T9 to T12

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28
Q

What is the conical structure that is the end of the spinal cord called?

A

Conus medullaris (between L1, 2)

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29
Q

What is the film terminale?

A

Extension of pia mater that extends from conus medullaris to the arachnoid and dura mater at the coccyx
- anchors spinal cord to coccyx

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30
Q

How many pairs of spinal nerves are there - and where do they all arise from?

A

31 pairs

  • 8 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 1 coccyx
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31
Q

What is contained in a dorsal root ganglion?

A

Cell bodies of sensory neurons

32
Q

What is in the white matter of the spinal cord?

A

Bundles of myelinated axons of neurons

33
Q

What are the anterior median fissure and posterior median sulcus of the spinal cord?

A

Anterior median fissure - wide groove on ventral side

Posterior median sulcus - narrow furrow on dorsal side

34
Q

What is contained in the grey matter of the spinal cord?

A

Dendrites and cell bodies of neurons, unmyelinated axons and neuroglia

35
Q

What is there grey commissure?

A

Crossbar between the two lateral sides of the grey matter

36
Q

What is found in the centre of the grey commissure?

A

Central canal - contains CSF

37
Q

What is the central canal continuous with in the medulla oblongata?

A

The fourth ventricle

38
Q

What are nuclei?

A

Clusters of neuronal cell bodies arranged in functional groups in the grey matter

39
Q

What parts of the spinal cord are the intermediate grey horns found in, and what do they contain?

A

Thoracic and upper lumbar

Contain autonomic motor nuclei - regulate activity of cardiac muscle, smooth muscle and glands

40
Q

What is the difference between a nerve and a track?

A

Nerves are bundles of axons in PNS

Tracts are bundles of axons in the CNS

41
Q

Describe A-alpha axons from the skin.

- size, speed, amount of myelin, sensory receptors

A 
Largest nerve fibre (12.20micrometers)
Fastest speed (80-120m/sec) due to thickest covering of myelin 
Carry Proprioception do skeletal muscle fibres
42
Q

Describe A-beta axons from the skin.

- size, speed, amount of myelin, sensory receptors

A

Second largest after A-alpha (6-12micrometers)
Second fastest after A-alpha (35-75m/sec) due to second thickest covering of myelin
Carries mechanoreceptors of the skin fibres

43
Q

Describe A-delta axons from the skin.

- size, speed, amount of myelin, sensory receptors

A

Second smallest nerve fibre (1-5micrometers)
Second slowest nerve fibre (5-30m/sec) due to smallest covering of myelin
Carriers pain and temperature fibres

44
Q

Describe C-fibre axons from the skin.

- size, speed, amount of myelin, sensory receptors

A

The smallest nerve fibre (0.2-1.5micrometers)
The slowest fibre (0.5-2m/sec) due to no myelin covering
Carries temperature, pain and itch fibres

45
Q

Which ganglia are pain receptor cell bodies for the face located in?

A

Trigeminal ganglia

46
Q

When are nociceptors activated?

A

When the pain reaches a noxious threshold

47
Q

Describe pain sensitisation in relation to nerve fibres?

A

Continued stimulation decreases the threshold at which nociceptors respond

48
Q

What type of pain do the A-delta fibres send to the brain?

A

Localised, sharp ‘first’ pain

- responds to intense mechanical and thermal stimuli

49
Q

What type of pain do the C-fibres send to the brain?

A

The poorly localised, diffuse ‘second’ pain (slow and burning)
- polymodal; respond to mechanical, thermal and chemical stimuli

50
Q

Name the three neurotransmitters used by nociceptive fibres.

A

Glutamate
Substance P
Calcitonin gene-related peptide (CGRP)

51
Q

Nociceptive activation causes what to happen locally?

A

Neurotransmitter release centrally and peripherally

Redness, tenderness and swelling in the periphery

52
Q

What are silent nociceptors?

A

Activated by peripheral neurotransmitters to expand to receptive field for painful stimuli

53
Q

Activation of nociceptors leads to opening of cation channels (mainly sodium), which causes what?

A

Membrane depolarisation and generation of action potentials

54
Q

How does a thermal stimuli activate A-delta and C-fibres?

A

Hot activates the TRPV1 receptor
Cold activates the TRPM8 receptor
Results in either cooling or warming of the body behaviours
- mediated through projections to the hypothalamus

55
Q

How does a mechanical stimuli activate A-delta and C-fibres

A

High threshold

Only activated when stimuli is noxious and may cause tissue damage

56
Q

How does a chemical stimuli activate C-fibres?

A

Can be external irritation or substances released during tissue damage

57
Q

What chemicals are released when tissues are injured?

A

Bradykinin
5-HT
Prostaglandins
Potassium ions

58
Q

How are C-fibres activated in general?

A

In response to the chemicals procured by tissues during tissue damage

  • CGRP and substance P are released
  • mast cells are simulated - histamine release
  • vasodilation, plasma extravasion, oedema and bradykinin release
59
Q

What happens to the activated threshold after the initial chemical release and vasodilation?

A

It is lowered to make the area more sensitive to pain

  • hyperalgesia
  • allondyia
60
Q

Describe the shift of balance of inputs in the gate control theory of pain.

A

When hurt, an individual rubs the area that is sore to alleviate pain
Balance of inputs shifts from C and A-delta fibres, and towards the mechanoreceptive A-beta fibres

61
Q

Describe how shifting towards A-beta fires in the gate control theory works.

A

C and A-delta fibres activate projection neuron firing - causing pain
These can be inhibited by inhibitory interneurons (that are inhibited by nociceptive input)
A-beta firing is through the activate the inhibitory interneuron

62
Q

How do endogenous opiods and opiates work?

A

Stimulates PAG matter in the midbrain, which sends descending, inhibitory pathways that supresses transmission of pain signals

63
Q

Names the three classes of endogenous opioids.

A

Endorphins
Enkephaline
Dynorphin

64
Q

Name three types of opioid receptor.

A

mu
kappa
delta

65
Q

How is back pain managed between the ages of 5 and 20?

A

It’s likely to be mechanical - managed with analgesia, brief rest and physiotherapy

66
Q

What is the best way to manage back pain (in any age)?

A

Physiotherapy
Being as active as possible
Early management

67
Q

Describe the role of the GP in management of back pain

A

Diagnostic triage
Give accurate info
Additional support for patients who don’ return to work
Referral

68
Q

Describe the role of the pysiotherapist in management of back pain

A

Builds up muscles to cope with problems
Prevents and manages musculoskeletal disorders/other health problems
Works in hospital or community
Passive modalities to assist pain relief - electric stimulation
Provides pain relief

69
Q

Describe the role of the osteopath in management of back pain

A

Instant pain relief
Involves palpation, manipulation and massage
Works with bone, muscles and connective tissues to diagnose and treat abnormalities
Based in community and private sector

70
Q

What is osteopathy?

A

A system of diagnosis and treatment based on the theory that may diseases are associated with disorders of the MSK system

71
Q

What is chiropody?

A

Its based on the theory that all disorders can be traced to the incorrect alignment of bones, consequent malfunctioning of nerve and muscles

72
Q

Describe the role of the chiropodist in management of back pain

A

Instant pain relief
Involves manipulation - mainly of vertebrae
Works with bone, muscles and connective tissues to diagnose and treat abnormalities
Based in community and private sector

73
Q

Describe the role of the hospital specialist in management of back pain

A

Further evaluates, manages and treats the underlying problem causing the back pain
Cause may be mechanical, metabolic, malignant or infectious

74
Q

What is a ‘yellow flags’, when regarding back pain?

A

Psycho-social barriers to recovery

75
Q

List some yellow-flags of back pain.

A 
Belief that pain is harmful and debilitating 
Fear - avoidance behaviours 
Sickness behaviours - extended rest
Social withdrawal
Emotional problems - constant low mood
Problems at work
Financial problems
Overprotective family
Inappropriate expectations of treatment

Head, Neck And Neuro (19 decks)

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