Red Flags and Emergencies

Question 1

Describe the national back pain pathway

Answer 1

PATHWAY PICTURE

Question 2

Red flags?

Answer 2

• Age <20 or >60 - first back pain
• Non-mechanical, constant pain
• History of cancer
• History of steroids
• General malaise, fever, unexplained weight loss
• Structural deformity
• Saddle anaesthesia/paraesthesia +/- loss of bowel or bladder control
• Severe pain longer than 6 weeks

Question 3

Emergency presentations?

Answer 3

Cauda equina syndrome

Fracture with deteriorating neurology

These are time sensitive and may only have < 24 hours to treat

Question 4

Symptoms of cauda equina syndrome?

Answer 4

Various urinary upsets are common (painless retention with overflow) + back pain + sciatica

This is a syndrome that may be referred even with a slight suspicion

Question 5

Inital assessment of a spinal fracture involves?

Answer 5

Immobilisation and X-ray

TREAT OTHER INJURIES

Question 6

Neurological examination?

Answer 6

Establish a motor and sensory level

Pay attention to the saddle area (if part of the saddle is spared, the prognosis is better)

Question 7

Initial assessment of cervical spine injuries?

Answer 7

X-ray must show C7/T1 (to ensure nothing is missed, e.g: a facet dislocation at that level)

Immobilise in the “natural” position, not a rigid position

Do a neurological exam

TREAT OTHER INJURIES

Question 8

Initial assessment of a thoracolumbar injury?

Answer 8

Often T12 OR L1 are affected
Rigid spine board for immobilisation

Carry out an accurate neurological exam

TREAT OTHER INJURIES

Question 9

Factors that influence spinal cord involvement in injuries?

Answer 9

Size of the spinal canal and location of the injury

Bone “pinching”

Contact pressure (from a bone/disc)

This can be severe, even if the bone injury is not severe, e.g: in children/elderly

Question 10

Types of secondary spinal cord damage?

Answer 10

Cord swelling

Oedema

Ischaemia

Thrombosis of small vessels

Venous obstruction

Question 11

What factors can precipitate spinal cord damage?

Answer 11

Rarely, moving a spinal patient causes problems; other issues, like hypoxia, hypoxaemia and poor perfusion carry a much greater risk

Question 12

Patterns of spinal cord injury?

Answer 12

Complete (spinal cord is fully compressed or severed and no signals are sent past this point)

Incomplete (spinal cord is compressed or injured but signals are not completely removed)

Question 13

Syndromes caused by incomplete spinal cord injury?

Answer 13

1. Central cord syndrome (most common form of cervical spinal cord injury and characterized by loss of motion and sensation in arms and hands)
2. Brown-Sequard syndrome (asymmetric damage to half of the spinal cord results in paralysis and loss of proprioception on the ipsilateral side as the injury and loss of pain and temperature sensation on the contralateral side) - this has the BEST PROGNOSIS
3. Anterior cord syndrome (anterior spinal artery is interrupted, causing ischemia/infarction of the spinal cord; deep touch, position and vibration are preserved) - POOR PROGNOSIS and may be caused by vascular insult, e.g: AAA complication

Question 14

Frankel/ASIA grading of spinal injury neurological effect?

Answer 14

I or A - complete motor and sensory loss
II or B - complete motor and incomplete sensory
III or C - incomplete motor (no practical use)
IV or D - useful motor and incomplete sensory
V or E - normal motor and sensory function

Question 15

Examination of a complete cord injury?

Answer 15

Must check for saddle sparing (even some sparing improves the prognosis)

Arms tend to be worse than legs

Question 16

Causes of central corn syndrome?

Answer 16

Typically a hyperextension injury, e.g: elderly patient falls

Question 17

Problems that can cause secondary cord damage?

Answer 17

Stretching
Compression
Undue movement
HYPOTENSION AND HYPOXAEMIA (WORST)
Inappropriate surgery
Infection

Question 18

Problems of the growing spine?

Answer 18

Growth plate disturbances - damage can cause premature fusion and cessation of growth; this can lead to kyphosis

Chance fractures and variants are part. seen in ADOLESCENTS, due to presence of growth plates and cartilaginous rims

Question 19

Features of ankylosing spondylitis?

Answer 19

Rigid spine with creation of long lever arms and soft porotic bone (makes fixation difficult)

Question 20

Assessment of ankylosing spondylitis of the spine?

Answer 20

Dangerous and unstable injury so CT IS MANDATORY

Can be made worse by rigid collars so immobilise in the “natural” position