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Year 2 Clinical > Prolapsed Intervertebral Disc and Mechanical Back Pain > Flashcards

Prolapsed Intervertebral Disc and Mechanical Back Pain Flashcards

1
Q

What to cover in a back pain history?

A

Onset of pain, site and nature

Previous episodes

Radiation of pain

Neurological symptoms:

  • Numbness
  • Paraesthesia
  • Weakness
  • Temperature disturbance
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2
Q

Timing of back pain?

A

Usually, insidious in onset and difficult to attribute to a certain date/incident

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3
Q

Red flag symptoms of back pain?

A

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

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4
Q

Examination of back pain?

A

Inspection

Test range of movement

Neurological assessment

Nerve root irritation

Distraction testing

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5
Q

Signs on inspection of the back?

A

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

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6
Q

How to assess range of movement of the spine?

A

SCHOBER’S TEST - measures skin stretch which closely relates to true spinal movement:

  1. Find the SI dimples
  2. Measure 10 cm above and 5 cm below
  3. Hold the top of the measuring tape
  4. Ask the patient to bend as far forward as they can
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7
Q

Interpretation of Schober’s test results?

A

Normal movement - about 21 cm

< 18 cm - pathologically stiff

> 24 cm - hypermobile

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8
Q

What should be observed on extension and lateral flexion of the spine?

A

Smooth movements, with no kinks

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9
Q

What does a neurological examination inv. ?

A

Testing:

Myotomes

Dermatomes

Reflexes

Nerve irritation, e.g: straight leg raise (for sciatic nerve roots) and femoral stretch test (for femoral roots)

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10
Q

Important myotomes allowing specific movements?

A

L1/2 - hip flexion

L3/4 - knee extension

L5 - foot dorsiflexion & EHL

S1/2 - ankle plantarflexion

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11
Q

How to test L1/2 hip flexion?

A

Ask the patient to push up against your hand

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12
Q

How to test L3/4 knee extension?

A

Ask the patient to straighten their knee against your hand

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13
Q

How to test L5 foot dorsiflexion and EHL?

A

Check dorsiflexion of the foot and also check extension of the hallux

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14
Q

How to test S1/2 ankle plantarflexion?

A

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

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15
Q

Which reflexes should be checked?

A

Knee jerk and ankle jerk reflexes

Plantar reflexes (scratch foot sole - big toe should flex)

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16
Q

Which nerve irritation tests can be done?

A

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)

17
Q

What should be looked for in nerve irritation tests?

A

Reproduction of the leg pain, not the back pain

18
Q

Signs of overt pain behaviour?

A

Guarding, bracing, rubbing, grimacing, sighing

19
Q

Types of behavioural responses?

A

Superficial/non-anatomical tenderness

Simulation – axial loading/rotation

Distraction – SLR (straight leg raising), etc

Over-reaction to examination

Regional – sensory disturbance, giving way

20
Q

Ix of back pain?

A

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

21
Q

How does an annular tear appear on MRI?

A

Little white triangle (AKA high intensity zone)

22
Q

Sciatica definition?

A

Buttock and/or leg pain in a specific dermatomal distribution accompanied by neurological disturbance.

23
Q

Features of disc prolapse?

A

AKA slipped disc

Can be asymptomatic; important feature is sciatica, often accompanied by neurological disturbance

24
Q

What is surgery in the case of a prolapsed disc used for?

A

For the LEG PAIN, not the back pain

25
Q

Common presentation of disc prolapse?

A

Episodic back pain

Onset of leg pain +/- neurology

Leg pain eventually becomes dominant

Myotomes and dermatomes

26
Q

Treatment of disc prolapse?

A

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

27
Q

Problems with surgery for a disc prolapse?

A

Surgery carries a risk

Long-term results are the same whether or not the operation was done

28
Q

Conservative management of back ache?

A
  • Short bed rest (debatable) - if too painful
  • Anti-inflammatory +/- muscle relaxant
  • MOBILISE thereafter
  • Place of physical therapies, X-ray etc
  • Return to normal activity
29
Q

2nd line treatments for back pain?

A

Education/instruction/reassurance

PHYSIOTHERAPY

Osteopathy/chiropractic

TENS/psychology/pain clinic

Complementary therapies

Surgery

30
Q

What is adjacent segment disease?

A

Sometimes, surgery simply knocks the back problem up a segment

A symptomatic deterioration of spinal levels adjacent to the site of a previous fusion

31
Q

Adverse prognostic factors in spinal surgery?

A

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

32
Q

Behavioural symptoms of back pain?

A
  • 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
33
Q

Psychosocial yellow flags in back pain?

A
  • Belief that back pain is harmful or potentially seriously disabling
  • Fear avoidance behaviour
  • Low mood/withdrawal
  • Passive rather than active
34
Q

What does a hamburger sign indicate?

A

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

Year 2 Clinical (119 decks)

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