Regional Adult Orthopedics - Spine

Question 1

majority of back cases will be “mechanical” back pain with serious pathology

Answer 1

F

mechanical back pain - no serious pathology

Question 2

How to treat mechanical back pain?

Answer 2

Advice and analgesia, with or without physiotherapy

Question 3

recurrent relapsing and remitting back pain with no neurological symptoms

Answer 3

MECHANICAL BACK PAIN

Question 4

Possible causes mechanical back pain?

Answer 4

obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis

Question 5

Bed rest is advised for mechanical back pain

Answer 5

F

Bed rest is not advised as this will lead to stiffness and spasm of the back which may exacerbated disability.

Question 6

Which patients may benefit from spinal stabilization surgery in cases of mechanical back pain?

Answer 6

• instability caused by OA on two adjacent disks, or degenrate discs AND NOT RESPONDING TO CONSERVATIVE MANAGEMENT
• No secondary gain or behavioural issues (i.e. disability appeal)

Question 7

long term results of spinal stabilization are totally curative

Answer 7

F

suggest recurrence of symptoms and no benefit after around 5 years

Question 8

SEVERE back pain worse on COUGHING following lifting a heavy object

Answer 8

Acute vertebral disc tear

Question 9

Why does acute vertebral disc tear cause severe pain?

Answer 9

tear can occur in the outer annulus fibrosis of an intervertebral disc, periphery of the disc is richly innervated and pain can be severe

Question 10

In acute disc tear symptoms usually settle in 2-3 months

Answer 10

T

Question 11

mainstay of treatment acute disc tear?

Answer 11

Analgesia and physiotherapy

Question 12

What is radiculopathy?

Answer 12

disc tear occurs, nucleus pulposis can “herniate” through the tear

Impinge on exiting nerve

Question 13

altered sensation in a dermatomal distribution
reduced power in a myotomal distribution
reduced reflexes

Answer 13

radiculopathy

bony nerve root entrapment

Question 14

What causes bony nerve root entrapment?

Answer 14

Osteophytes from OA of facet joints = impinges on nerves

Question 15

How can you treat bony nerve root entrapment?

Answer 15

Surgical decompression with trimming of the impinging osteophytes

Question 16

Intermittent claudication - CRAMPING
leg or hip pain during walking)
Numbness extremities
Loss of pulses
Colour change

Answer 16

Peripheral vascular disease

Question 17

INCOSISTENT claudication distance
Burning pain
Pain is LESS WALKING UPHILL
pulses well preserved
OVER 60 yr old

Answer 17

Spinal stenosis

Question 18

What is spinal stenosis?

Answer 18

cauda equina of the lumbar spine has less space - multiple nerve roots can be compressed / irritated.

Question 19

what does stenosis mean

Answer 19

narrowing

Question 20

What is spondylosis?

Answer 20

aging phenomenon
-intervertebral discs degenerate and weaken, which can lead to disc herniation and bulging discs
-OA and osteophytes
COMMON COMMON COMMON
(call it spendylosis - bones r SPENT)

Question 21

in spinal stenosis if symptoms fail to improve with conservative management and there is MRI evidence surgery may be performed (decompression to increase space for the cauda equina)

Answer 21

T

Question 22

a very large central disc prolapse can compress all the nerve roots of the cauda equina is called

Answer 22

cauda equina syndrome

Question 23

cauda equina syndrome is a surgical emergency

Answer 23

T

Question 24

It is negligent NOT to perform what is cauda equina syndrome is suspected?

Answer 24

PR exam

Question 25

bilateral leg pain
paraesthesia
saddle area numbness
incontinent 
constipated

Answer 25

CAUDA EQUINA SYNDROME

Question 26

Suspected cauda equina s. with +ve findings on PR - what now?

Answer 26

URGENT MRI - determine level of prolapse

URGENT DISCECTOMY once diagnosis confirmed

Question 27

IN cauda equina syndrome with prompt surgical intervention, significant number of patients have residual nerve injury with permanent bladder and bowel dysfunction

Answer 27

T

Question 28

What are the back pain red flags (4)

Answer 28

1. YOUNG (<20 yrs)
2. NEW back pain in OLD patient (>60yrs)
3. Pain is CONSTANT, SEVERE, WORSE AT NIGHT
4. Systemic upset

Question 29

Adolescents with severe back pain are at the peak age to have?

Answer 29

Primary bone tumors

Question 30

Back pain in the older patient may represent?

Answer 30

arthritic change or a crush fracture

higher risk of neoplastic changes

Question 31

Treatment for osteoporotic crush fractures?

Answer 31

Conservative treatment or balloon vertebroplasty

Question 32

Severe osteoporosis
Acute pain
Kyphosis

Answer 32

Osteoporotic crush fracture

Question 33

Slow onset stiffness 
Pain in the neck (radiates to shoulder and occiput)
upper limb dermatomal paraesthesita
upper limb myotomal muscle weakness
Loss of reflexes

Answer 33

Cervical spondylosis

Question 34

Atraumatic cervical spine instability can occur in?

Answer 34

Down syndrome and rheumatoid arthritis

Question 35

Rheumatoid arthritis causes which types of cervical spine instability and why?

Answer 35

atlanto‐axial subluxation can also occur due to destruction of the synovial joint between atlas and dens

Lower cervical subluxation-destruction of the synovial facet joints

Question 36

Treatment for cervical spine instability?

Answer 36

Less sevre = collar

severe = surgical fusion

Question 37

How to check degree of cervical spine instability?

Answer 37

flexion‐extension xray

Question 38

Patient with acute lower back pain aged 42, has restricted leg raise on examination

Answer 38

Radiculopathy/sciatica due to prolapsed intervertebral disc due to age-related wear and tear
common age 30-50

Question 39

Prolapsed intervertebral disc always requires surgery

Answer 39

F

bed rest rehabilitation most cases