S P I N E

Question 1

history taking in back pain

Answer 1

SOCRATES

associated sx = parasthesia, motor deficit, radiation of pain elsewhere, history of trauma, weight loss, stiffness

red flags = saddle paraesthesia, urinary or faecal incontinence/ retention, pain that is waking patient from sleep, fevers/rigors

Question 2

what are back pain red flag ddx

Answer 2

Relating to CES – urinary/faecal incontinence or retention, saddle paraesthesia, progressive neurological deficits, impotence

Cancer – weight loss, night sweats, fever

Fracture – recent history of trauma

Infection – PWID, DM, immunocompromised persons

Question 3

what are the risk factors of back pain

Answer 3

Lack of physical activity
Increasing age
Obesity 
Arthritis
Heavy lifting
Psychological conditions
Smoking

Question 4

describe the nature of ligamentous/ msk related back pain

Answer 4

Typically a history of heavy lifting or pain that started with a sudden movement

Pathology – spraining of back muscles

May present with painful spasms

Located in the paraspinal region

Question 5

describe the management of ligamentous/ msk back pain

Answer 5

Conservative management is the mainstay
Advise the patient to keep active
Prescribe NSAIDs (plus PPI cover) if no contraindications
Consider referral to PT
Other – CBT, osteopath
Reassurance and safety netting

Question 6

describe the pathology of degenerative disc disease

Answer 6

age-related degeneration of intervertebral discs, causing weakness and collapse.

This may be dehydration of the nucleus pulposus or tears in the annulus fibrosis. Other contributing factors include osteoporosis, spinal surgery and spinal fracture

Question 7

describe the features of degenerative disc disease

Answer 7

majority asymptomatic. Other presentations may include paraspinal tenderness, hypo-mobility and paraesthesia if severe

Question 8

lx and management of degenerative disc disease

Answer 8

imaging not routinely required - MRI is gold standard

Analgesia, including use of neuropathic agents

Encouraging mobilisation as able

Referral to pain clinic if symptoms not resolving

Acute (red flag symptoms) – urgent decompression

Question 9

what is radiculopathy

Answer 9

Conduction block in the axons or root of a spinal nerve
Spectrum of neurological phenomena such as altered sensation and weakness

Usually a result of nerve impingement

Question 10

causes of radiculopathy

Answer 10

Disc prolapse
Degenerative disease
Malignancy 
Fracture 
Infection

Question 11

what is sciatica and its features

Answer 11

form of radiculopathy known as lumbar radiculopathy

Paraesthesia
Shooting, burning pain. This may radiate down the back of the leg to the foot in sciatica
Weakness
Exclude red flag features

Question 12

management of radiculopathy

Answer 12

Conservative is the mainstay

Encourage activities and mobilisation

Analgesia +/- neuropathic medications and benzodiazepines

PT

Operative management for disc prolapse if refractory to conservative measures

Definitive management depends on the underlying cause

Question 13

give 3 examples of spine infection

Answer 13

Spondylitis – i.e. osteomyelitis (vertebral body)

Abscess

Discitis – isolated infection of vertebral disc

rare but serious, requires ongoing investigations and treatment

Question 14

features of spinal infection

Answer 14

(Localised) back pain
Fever and rigors
Radiculopathy
Neurological deficit

Question 15

spread of infection in spine

Answer 15

– haematogenous (People who Inject Drugs), direct (surgery, spinal anaesthesia), adjacent spread.

Question 16

organisms in spina infection

Answer 16

s. aureus e.coli

Question 17

spinal infection investigations and management

Answer 17

Bloods – FBC, CRP, Blood Cultures, etc.
Imaging – MRI gold standard
CT-guided biopsy

Long term IV antibiotics
Surgical – if failure of conservative management, bony destruction

Question 18

what is the presentation of c spine fracture, lx and mangement

Answer 18

Neck pain the presenting feature (beware distracting injuries)

Varying spectrum of neurological presentation

Investigations – CT cervical spine (MRI in paediatrics)

Management – ATLS principles, C-spine immobilisation as per Canadian C-Spine Rules, conservative if stable, operative if unstable #

Question 19

what are the causes of spinal cord compression

Answer 19

Metastatic malignancy is by far the commonest cause - breast, prostate, lung

Other causes – traumatic, prolapsed disc, infection

Question 20

what investigations are requires in spinal cord compression

Answer 20

MRI whole spine

Bloods – investigate for cause of SCC

Question 21

what is the presentation of cord compression

Answer 21

Deficits in sensation and proprioception

Upper motor neurone defects - UMN – hyperreflexia, Babinski’s, hypertonia.

Question 22

what is the management for spinal cord compression

Answer 22

High dose corticosteroids

Surgical decompression

If malignant cause, concurrent radio/chemotherapy

Question 23

what is CED

Answer 23

Compression of the nerve roots below the conus medullaris

A neurosurgical emergency, likewise requiring prompt diagnosis and treatment

Question 24

Causes of CES

Answer 24

prolapsed disc (commonest), neoplastic, infection, trauma, iatrogenic

Question 25

Presentation in CES

Answer 25

Lower motor neurone deficits 
Reduced lower limb sensation
Urinary retention/faecal incontinence 
Saddle paraesthesia
Impotence 
Back pain 
(May be incomplete CES – some control of urinary function maintained)

Question 26

CES on examination

Answer 26

LMN deficits on neurological examination
Loss of anal tone
Loss of perianal sensation
Retention on a post-void bladder scan

Question 27

lx and management of CES

Answer 27

MRI (lumbosacral)

Management

Early referral to neurosurgical team
Urgent surgical decompression