PBL- Back Pain Leading To Chronic Incapacity Flashcards
What are the red flags of lower back pain?
Previous history of malignancy Younger than 16, older than 50 with new pain Weight loss Prolonged steroid use Recent serious illness Recent significant infection
List some mechanical causes of lower back pain below.
Trauma Muscular and ligament pain Pustular back pain Facts joint syndrome Lumbar disk prolapse Lumbar spondylosis
Describe the anatomy of an intervertebral disk.
Soft gelatinous centre called nucleus pulposus, encircled by a strong, ring-like collar of fibrocartilage called the annulus fibrosis.
What is the main function of an intervertebral disk?
Shock absorption
What happens in an intervertebral disk prolapse?
Nucleus pulposus is squeezed out of place and herniated through the annulus fibrosis
Name some reasons an IV disk would become damaged?
Trauma
Effects of aging
Degenerative disorders of the spine
Briefly describe pathology involved once an IV disk herniation has occurred?
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
Which regions of the spine are most commonly involved in disk herniations?
Cervical and lumbar
Where are the signs and symptoms of a disk herniations seen?
Localised to the area of the body innervated by the affected spinal nerve roots- includes motor and sensory
If the nerve roots L4, L5, S1, S2 and S3 are damaged, what condition arises?
Sciatica
Describe where the pain is felt in sciatica?
Spreads down the back of the leg and over the sole of the foot
What are the most common sensory effects from spinal root compression?
Paraesthesia and numbness
What are the most common motor effects from spinal root compression?
Knee and ankle reflexes may be absent or diminished
What are the symptoms of severe spinal disease?
Pain worse at rest Thoracic pain Fever General malaise Urinary retention
What signs and symptoms of cord compression occur in severe spinal disease?
Back pain Leg weakness Limb numbers Ataxia Urinary retention Hyperreflexia Clonus
What signs and symptoms of cauda equina compression occur in severe spinal disease?
Bilateral leg pain Back pain Urinary retention Perinatal sensory loss Erectile dysfunction Reduced anal tone
What are the layers of protection for the spinal cord?
Vertebrae Vertebral ligaments Fat and connective tissue in epidural space Meninges CSF
At what point do the spinal nerves stop being covered in meninges?
Once they exit the spinal column through the intervertebral foramen
What is the epineurium?
The outer covering of spinal and cranial nerves
- continuous with dura mater
Describe the connective tissues of the dura mater.
Thick, strong, dense and irregular
Describe the connective tissues of the arachnoid mater.
Thin, avascular with loosely arranged collagen and elastic fibres
Describe the connective tissues of the pia mater.
Thin and transparent
Bundles of collagen fibres and some elastic fibres
- adheres to surface of spinal cord and brain
Which meningeal layer contain blood vessels? (At least in the spine :/)
Pia mater and dura mater
What are denticulate ligaments?
Triangular shaped membranous extensions of the pia mater than suspend the spinal cord in the middle of the rural sheath
Where does the spinal cord arise and terminate in adults and babies?
Arises in the medulla oblongata
Terminates
- superior border of 2nd lumbar vertebrae in adults
- L3,4 in newborns
What is the superior enlargement of the spinal cord, and where does it span?
It’s a cervical enlargement, that nerves to and from the upper limb arise from
Spans from C4 to T1
What is the inferior enlargement of the spinal cord, and where does it span?
It’s a lumbar enlargement, that nerves to and from the lower limb arise from
Spans from T9 to T12
What is the conical structure that is the end of the spinal cord called?
Conus medullaris (between L1, 2)
What is the film terminale?
Extension of pia mater that extends from conus medullaris to the arachnoid and dura mater at the coccyx
- anchors spinal cord to coccyx
How many pairs of spinal nerves are there - and where do they all arise from?
31 pairs
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccyx
What is contained in a dorsal root ganglion?
Cell bodies of sensory neurons
What is in the white matter of the spinal cord?
Bundles of myelinated axons of neurons
What are the anterior median fissure and posterior median sulcus of the spinal cord?
Anterior median fissure - wide groove on ventral side
Posterior median sulcus - narrow furrow on dorsal side
What is contained in the grey matter of the spinal cord?
Dendrites and cell bodies of neurons, unmyelinated axons and neuroglia
What is there grey commissure?
Crossbar between the two lateral sides of the grey matter
What is found in the centre of the grey commissure?
Central canal - contains CSF
What is the central canal continuous with in the medulla oblongata?
The fourth ventricle
What are nuclei?
Clusters of neuronal cell bodies arranged in functional groups in the grey matter
What parts of the spinal cord are the intermediate grey horns found in, and what do they contain?
Thoracic and upper lumbar
Contain autonomic motor nuclei - regulate activity of cardiac muscle, smooth muscle and glands
What is the difference between a nerve and a track?
Nerves are bundles of axons in PNS
Tracts are bundles of axons in the CNS
Describe A-alpha axons from the skin.
- size, speed, amount of myelin, sensory receptors
Largest nerve fibre (12.20micrometers) Fastest speed (80-120m/sec) due to thickest covering of myelin Carry Proprioception do skeletal muscle fibres
Describe A-beta axons from the skin.
- size, speed, amount of myelin, sensory receptors
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
Describe A-delta axons from the skin.
- size, speed, amount of myelin, sensory receptors
Second smallest nerve fibre (1-5micrometers)
Second slowest nerve fibre (5-30m/sec) due to smallest covering of myelin
Carriers pain and temperature fibres
Describe C-fibre axons from the skin.
- size, speed, amount of myelin, sensory receptors
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
Which ganglia are pain receptor cell bodies for the face located in?
Trigeminal ganglia
When are nociceptors activated?
When the pain reaches a noxious threshold
Describe pain sensitisation in relation to nerve fibres?
Continued stimulation decreases the threshold at which nociceptors respond
What type of pain do the A-delta fibres send to the brain?
Localised, sharp ‘first’ pain
- responds to intense mechanical and thermal stimuli
What type of pain do the C-fibres send to the brain?
The poorly localised, diffuse ‘second’ pain (slow and burning)
- polymodal; respond to mechanical, thermal and chemical stimuli
Name the three neurotransmitters used by nociceptive fibres.
Glutamate
Substance P
Calcitonin gene-related peptide (CGRP)
Nociceptive activation causes what to happen locally?
Neurotransmitter release centrally and peripherally
Redness, tenderness and swelling in the periphery
What are silent nociceptors?
Activated by peripheral neurotransmitters to expand to receptive field for painful stimuli
Activation of nociceptors leads to opening of cation channels (mainly sodium), which causes what?
Membrane depolarisation and generation of action potentials
How does a thermal stimuli activate A-delta and C-fibres?
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
How does a mechanical stimuli activate A-delta and C-fibres
High threshold
Only activated when stimuli is noxious and may cause tissue damage
How does a chemical stimuli activate C-fibres?
Can be external irritation or substances released during tissue damage
What chemicals are released when tissues are injured?
Bradykinin
5-HT
Prostaglandins
Potassium ions
How are C-fibres activated in general?
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
What happens to the activated threshold after the initial chemical release and vasodilation?
It is lowered to make the area more sensitive to pain
- hyperalgesia
- allondyia
Describe the shift of balance of inputs in the gate control theory of pain.
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
Describe how shifting towards A-beta fires in the gate control theory works.
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
How do endogenous opiods and opiates work?
Stimulates PAG matter in the midbrain, which sends descending, inhibitory pathways that supresses transmission of pain signals
Names the three classes of endogenous opioids.
Endorphins
Enkephaline
Dynorphin
Name three types of opioid receptor.
mu
kappa
delta
How is back pain managed between the ages of 5 and 20?
It’s likely to be mechanical - managed with analgesia, brief rest and physiotherapy
What is the best way to manage back pain (in any age)?
Physiotherapy
Being as active as possible
Early management
Describe the role of the GP in management of back pain
Diagnostic triage
Give accurate info
Additional support for patients who don’ return to work
Referral
Describe the role of the pysiotherapist in management of back pain
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
Describe the role of the osteopath in management of back pain
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
What is osteopathy?
A system of diagnosis and treatment based on the theory that may diseases are associated with disorders of the MSK system
What is chiropody?
Its based on the theory that all disorders can be traced to the incorrect alignment of bones, consequent malfunctioning of nerve and muscles
Describe the role of the chiropodist in management of back pain
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
Describe the role of the hospital specialist in management of back pain
Further evaluates, manages and treats the underlying problem causing the back pain
Cause may be mechanical, metabolic, malignant or infectious
What is a ‘yellow flags’, when regarding back pain?
Psycho-social barriers to recovery
List some yellow-flags of back pain.
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
