Prolapsed Intervertebral Disc Flashcards
What are the 3 components of back pain
Biological
Psychological
Social
What neurological symptoms are important to ask about
Numbness
Paraesthesia
Weakness
Temperature disturbance
What are 4 red flag features of back pain in the history
Non-mechanical pain (does not vary with activity - also troublesome at night)
Systemic upset
Major, new, neurological deficit (suspicious of cord compression)
Saddle anaesthesia +/- bladder or bowel upset (surgical emergency)
What happens in saddle anaesthesia
Painless retention of urine with overflow and a lack of awareness of the bowels opening
What do we look for on examination from the back and side
Deformity Asymmetry Hairy patches Neurofibromata Masses Bulges
What does forward bending do
Accentuate any structural deformity - exentuate saddle deformity
Scolliosis
What does the normal movement go to during forward bending in Schober’s Method
21cm
What is a movement of less than 18cm suggest
Pathologically stiff
What is a movement range of more than 21cm indicate
Hypermobile
What should you see on lateral movements
Smooth curve eitherway
What are the 4 tests in the neurological examination
Myotomes
Dermatomes
Reflexes
Nerve irritation (straight leg raise)
What are the myotomes for
1) hip flexion
2) knee extension
3) foot dorsiflexion and Extensor halls longus
4) ankle plantarflexion
1) L1,2
2) L3,4
3) L5
4) S1,2
How do we test L1,2
Hip flexion
With a bent knee as the patient to push up against your hand
How do we test for L3,4
Knee extension
Ask the patient to straighten their knee against your hand with knee at 45 degrees
How do we test L5
Extension or dorsiflexion of the foot
How do we test S1,S2
Plantar flex the foot against your hand
Powerful movement and deficit needs to be gross to pick it up
Ask the patient to stand on tip toes for more subtle deficits
What is different about the way we test plantar reflexes?
We use the opposite end of the tendon hammer and scratch the sole of the foot
How do we perform the femoral stretch test
Patient on their side, flex the knee to 90 degrees and extend their hip
How do we test distraction SLR
Ask the patient to sit at 90degrees with the legs straight
What is the gold standard investigation for back pain
MRI / CT
What is a patients definition of Sciatica
Any sort of vague buttock or leg pain
What is a GPs definition of sciatica
Any sort of buttock or leg pain not obviously coming from the hip, knee or ankle
What is a spinal surgeon’s definition of sciatica
Buttock and / or leg pain in a specific dermatomal distribution accompanied by neurological disturbance
What is an important feature of a prolapsed disc
Leg pain (sciatica) often accompanied by neurological disturbance
Disc prolapse are always symptomatic. True or false
False
What is the purpose of surgery for a prolapsed disc
To treat leg pain or sciatica - not normally back pain
What are 4 common presentations of disc prolapse
Episodic back pain
Onset of leg pain +/- neurology
Leg pain becomes dominant
Myotomes and dermatomes will tell you where the prolapsed disc is
What generally do we do for disc prolapses
Leave them (conservative) Only surgery for cauda equina symptoms
What are some of the second line treatments for a prolapsed disc
Education/ instruction and reassurance physio Osteopathy / chiropractic TENS/ psychology / pain clinic Complementary therapies Surgery
What is the difference between stress and distress
Stres is a normal emotion in response to life
Distress is excessive or abnormal stress response
What are some symptoms of stress
Feeling under pressure Feeling overwhelmed Chronic fatigue Anxiety Muscle tension Aches and pain Sweaty hands
