Prolapsed Intervertebral Disc and Mechanical Back Pain Flashcards
What to cover in a back pain history?
Onset of pain, site and nature
Previous episodes
Radiation of pain
Neurological symptoms:
- Numbness
- Paraesthesia
- Weakness
- Temperature disturbance
Timing of back pain?
Usually, insidious in onset and difficult to attribute to a certain date/incident
Red flag symptoms of back pain?
Non-mechanical pain indications, e.g: does not vary with activity, constant pain, troublesome at night
Systemic upset
Major, new neurological deficit
Saddle anaethesia +/- bladder/bowel upset
Examination of back pain?
Inspection
Test range of movement
Neurological assessment
Nerve root irritation
Distraction testing
Signs on inspection of the back?
Deformities, asymmetry, hairy patches, neurofibromata and others
Ask the patient to bend forward to exaggerate any structural deformities, e.g: scoliosis or angular deformity of a Gibbus
How to assess range of movement of the spine?
SCHOBER’S TEST - measures skin stretch which closely relates to true spinal movement:
- Find the SI dimples
- Measure 10 cm above and 5 cm below
- Hold the top of the measuring tape
- Ask the patient to bend as far forward as they can
Interpretation of Schober’s test results?
Normal movement - about 21 cm
< 18 cm - pathologically stiff
> 24 cm - hypermobile
What should be observed on extension and lateral flexion of the spine?
Smooth movements, with no kinks
What does a neurological examination inv. ?
Testing:
Myotomes
Dermatomes
Reflexes
Nerve irritation, e.g: straight leg raise (for sciatic nerve roots) and femoral stretch test (for femoral roots)
Important myotomes allowing specific movements?
L1/2 - hip flexion
L3/4 - knee extension
L5 - foot dorsiflexion & EHL
S1/2 - ankle plantarflexion
How to test L1/2 hip flexion?
Ask the patient to push up against your hand
How to test L3/4 knee extension?
Ask the patient to straighten their knee against your hand
How to test L5 foot dorsiflexion and EHL?
Check dorsiflexion of the foot and also check extension of the hallux
How to test S1/2 ankle plantarflexion?
Very powerful movement and the deficit needs to be gross before it can be picked up
More subtle deficits can be detected by asking the patient to stand on tip toe
Which reflexes should be checked?
Knee jerk and ankle jerk reflexes
Plantar reflexes (scratch foot sole - big toe should flex)
Which nerve irritation tests can be done?
Straight leg test; further extension of the foot (sciatic stretch test) or pressure behind the knee (bowstring test) can be added
Femoral stretch test (patient lies supine, knee is extended and patient’s leg is lifted - +ve test if anterior thigh pain is felt)
What should be looked for in nerve irritation tests?
Reproduction of the leg pain, not the back pain
Signs of overt pain behaviour?
Guarding, bracing, rubbing, grimacing, sighing
Types of behavioural responses?
Superficial/non-anatomical tenderness
Simulation – axial loading/rotation
Distraction – SLR (straight leg raising), etc
Over-reaction to examination
Regional – sensory disturbance, giving way
Ix of back pain?
X-rays (little use - tend to show no unexpected abnormalities)
MRI (gold standard but produce a lot of false +ve results)
Diagnostic facet injection
Contrast enhanced CT scan
Provocation discography
Selective nerve block/ablation
How does an annular tear appear on MRI?
Little white triangle (AKA high intensity zone)
Sciatica definition?
Buttock and/or leg pain in a specific dermatomal distribution accompanied by neurological disturbance.
Features of disc prolapse?
AKA slipped disc
Can be asymptomatic; important feature is sciatica, often accompanied by neurological disturbance
What is surgery in the case of a prolapsed disc used for?
For the LEG PAIN, not the back pain
Common presentation of disc prolapse?
Episodic back pain
Onset of leg pain +/- neurology
Leg pain eventually becomes dominant
Myotomes and dermatomes
Treatment of disc prolapse?
NOT an emergency but BEWARE CAUDA EQUINA SYNDROME
Most settle within 3 months so avoid surgery in this time; rest tend to settle in 18-24 months but this is too long for some people and surgery may be used
Problems with surgery for a disc prolapse?
Surgery carries a risk
Long-term results are the same whether or not the operation was done
Conservative management of back ache?
- Short bed rest (debatable) - if too painful
- Anti-inflammatory +/- muscle relaxant
- MOBILISE thereafter
- Place of physical therapies, X-ray etc
- Return to normal activity
2nd line treatments for back pain?
Education/instruction/reassurance
PHYSIOTHERAPY
Osteopathy/chiropractic
TENS/psychology/pain clinic
Complementary therapies
Surgery
What is adjacent segment disease?
Sometimes, surgery simply knocks the back problem up a segment
A symptomatic deterioration of spinal levels adjacent to the site of a previous fusion
Adverse prognostic factors in spinal surgery?
Litigation
Dispute with DSS
Chronic Pain Syndrome (altered central pain perception that is often a stress response, like childhood abuse, PTSD, white coat distress, e.g: back pain, fibromyalgia, chronic fatigue, IBS, etc)/ behaviour
Behavioural symptoms of back pain?
- Pain at tip of coccyx
- Whole leg pain
- Whole leg numbness
- Whole leg giving way
- Absence of pain free spells
- Intolerance of treatment
- Emergency admission
Psychosocial yellow flags in back pain?
- Belief that back pain is harmful or potentially seriously disabling
- Fear avoidance behaviour
- Low mood/withdrawal
- Passive rather than active
What does a hamburger sign indicate?
CT appearance of an uncovered vertebral articular facet when the facet joint is dislocated, most often in cases of locked facet; indicates severe ligamentous disruption and spinal instability
