Spinal conditions Flashcards
clinical features of mechanical back pain
comes on suddely in 60% of cases
-reported bending or lifting episode
v common- 80% of adults get it at some point
can be present with or without assoc leg pain
ALWAYS RULE OUT RED FLAG FEATURES
differential diagnossi for mechanical back pain 10
mechanical back pain
OA of spine
prolpased intervertebral disc
spinal stenosis
spondlyolisthesis
discitis
inflammatory causes
malignancy
fracture
referred
-abdo
-hip pevlis SI joints
red flag syx of lower back apin 5
age <20 or >50
history of previous malignancy
night pain
history of trauma
systemically unwell
-weight loss
-fever
Ix for mechanical back pain 6
no Ix needed unless differential is suspected
patients with short history <6wks do not need routine investigations
prolonged syx or red flags:
-FBC with differential WCC
-ESR
-LFTs
-Bone profile
-Myeloma screen
-CRP
management of mechanical back pain 4
promote patient education
early syx control w simple analgesia
early return to normal activities
self referral to physiotherapists
what is nerve root impingement often a consequence of
degenerative disc disease
intervertebral disc herniation is most common in 3rd and 4th decades
where do the majority of intervertebral disc herniations occur
over 95% occur at L4/5 or L5/S1
basic pathophys of intervertebral disc heriniations leading to nerve root impingement
nucleus pulpous prolapses out via a defect in degenerative annulus fibrous
compresses the adjacent nerve root or the exiting nerve root, depending on location of disc herniation
syx of nerve root impingement 2
radicular pain passes below the knee and follows the dermatome of the involved nerve root
leg pain caused by hernitated disc is commonly equal to or worse in severity to that of the back pain itself
test for nerve root impingement 1
-diagnostic sign in this test
straight leg raising
-pain with SLR due to increased nerve root tension and lack of normal excursion of the root at the herniation site
Lasegue sign (this is the finding found in SLR)
-causes pain in ipsilateral leg distal to knee
-if contralateral leg pain this is a sign of disc herniation
diagnosis of nerve root impingement 1
MRI
what are indications for an MRI in a suspected nerve root impingement patient 3
patient present with radicular pain >6wks who have failed conservative measures
patients who develop neurologic deficits
bilateral lower limb deficits or peroneal syx
-NEED URGEN REFERRAL TO ORTHOPAEIDS AND EMERGENCY MRI TO RULE OUT CAUDA EQUINA
define radicular pain
type of pain that radiates from your back and hip into your legs through the spine
non-surgical management of nerve root impingement patient 4
majority non surgically:
-physiotherapy
-analgesic (simple analgesia and NSAIDs)
-muscle relaxants (limited short course initially)
-alternative therapies (acupuncture)
when could surgery be considered for nerve root impingement patient
no earlier than 6 weeks from onset of syx
UNLESS:
-cauda equina syndrome
-progressive neurological deficits
absoliute indcations for nerve root impingement surgery 2
cauda equina syndrome
progressive neurological deficit
relative indications for nerve root impingement surgery 3
intractable radicular pain
neurological deficit not improving conservatively
recurrent sciatica following successful trial of conservative measures
what are 5 serious spinal pathology
cauda equina syndrome
infection
tumour and spinal cord compression
spinal injuries
inflammatory conditions (Ank Spon)
red flag spinal pathology features 10
<18 or >50 at onset of non-mechanical pain
bilateral radicular leg pain
limb weakness
bladder or bowel dysfunction
peri-anal numbness
Hx of cancer
constituaonal syx
trauma
thoracic pain
history of immuno-compromise or prolonged steroid use
clinical features of cauda equina syndrome 2
bilateral syx of paresthia or mscule weakness
enquire about:
-saddle parestehia
-bladder and bowel dysfunction
red flag cauda equina syndrome history compoentes 4
back pain w uni/bilateral sciatica
lower limb weakness
altered perianal sensation
faecal or urinary incontinence
examination red flag features of cauda equina syndrome 5
limb weakness
other neuro deficits/ gait disturbance
hyper-reflexia, clonus, up-going plantars
urine retention
DRE- saddle anaetehisa, loss of anal tone
investigations of cauda equina syndrome 3
full history and exam
-DO PR W SENSATION AND ANAL TONE
bladder scan pre and post void to assess for bladder emptying
if sus of CEs-> urgert MRI
managemetn of cauda equina syndrome 1
urgent surgical decompression
MRI findings in cauda equina syndrome 2
complete obliteration of spinal canal space
compression of cauda equina
define discitis
infection of the disc space
define vertebral osteomyeltis
infection of vertebral body
assoications with discitis and vertebral osteomyelitis 3
IV drug use
sepsis from another source
post spinal surgery
organisms causing discitis and vertebral osteomyelitis 4
staph and strep most common
strep and haemophilus in children
tuberculosis -should be considered
clinical presenation of discitis and vertebral osteomyelitis 4
fever
generally unwell
back pain (unrelenting)
late cases can have spinal deformity
-kyphosis
-scoliosis
investigations of discitis and vertebral osteomyelitis 5
blood
-WCC
-ESR
-CRP
imaging
-X-ray- look for deformities
-MRI- increased signal in intervertebral disc or bone/ collection/ assoc epidural abscess
management of discitis and vertebral osteomyelitis 3
biopsy via CT guided
appropriate IV ANx- minimum 6 wks
surgical treatment occasionally required
-stabilisation
-draining a large abscess
spinal tumour clinical presenation 2
in adults metastic tumours are most common spinal tumours
present with:
-pain
-neurological
*-always ask red flags
spinal tumour investigations 3
MRI whole spine
-esp if ptx hx of cancer and new onset back pain
bone scan
serum calcium
-check for hypercalcemia
overviwe of malignant spinal cord compression
occasionally patients with spine mets present with compression of spinal cord
THIS IS A NEURO EMERGENCY
emergency radiotehrapy or surgical decompression is usually indicated
what does spinal injuries include
includes fractures, subluxations and dislocations
as a result of direct or indirect trauma
state the two classifications for spinal fractures 2
high energy injuries
-RTAs, fall from height
low energy
-elderly patients with osteoporosis or metastatic disease
*-note 10-20% of ptx w spinal fractures have a second fracture at another level
spinal fracture types based on anatomy 3
isolated anterior column fractures
-wedge compression
-tends to be stable
column (burst fractures) or associated ligament injuries tend to be unstable
clinical assessment of spinal injuries in patients
high energy:
-ATLS perspective
-patients with facial or head injuries should be presumed to have a significant neck injury until proven otherwise
-patients log rolled w C-spine control when spinal injury suspected
on examination what are sx of spinal injuries 4
bony midline tenderness
clinical deformity or palpable step
boggy swelling or brusing
neurological compromise
features of spinal shock 2
bradycardia
hypotension
diagnosis and imaging for spinal injuries 3
XR
-C-spine
-AP/lateral/ peg view
T&L spine
-AP & lateral
CT
-for high energy injruies
-more than 1 column involvement
MRI
-if assessing ligament or spinal cord injuries
treatment of stable cervical spinal injuries 2
cervical
-cervical collar
-analgesia
treatment of stable thoracic and lumbar spinal injuries 2
thoracic and lumber
-early mobilisation
-bracing for symptomatic relief
treatment of unstable cervical spinal injuries 3
HALO jacket
cerivcal collar (extended duration)
ORIF
treatment of unstable thoracic & lumbar spinal injuries 3
ORIF
bracing (extended duration)
bed rest in medically unfit patients
first steps in spinal cord injuries 2
surgical decompression
stabilisation
define scoliosis
lateral deviation or rotational deformity of the spine
causes of scoliosis 4
idiopathic -most common
neuromuscular
congenital
secondary
clinical features of scoliosis 4
pain uncommon
-if present should prompt further investigation
rib hump
asymmetrical shoulder height
limb length inequality
chest expansion may be affected in severe deformites
treatment of mild curve scoliosis 2
majority of idiopathic curves
-conservative treatment
occasionally bracing if risk of progression of curve identified
treatment of moderate/severe curve scoliosis
more commonly assoc w neuromusclar condtions or congenital curves
-surgical correction to prevent progression
-or to prevent deformity compromising cardio/respiratory function
neuromusulcar conditions causing scoliosis
ncluding central nervous system disorders such as cerebral palsy and spinal cord injury; motor neuron disorders, for example, spinal muscular atrophy; muscle fiber disorders, for example, Duchenne muscular dystrophy; multifactorial disorders, for example, …
define kyphosis
exageratted forward rounding of the upper back
cause of kyphosis
poor posture in childhood
or scheuermanns kyphosis
-vertebrae dont develop properly
treatment of kyphosis
reduce weight bearing and strenusous activites
rarely- brace or surgery
define fixed and flexible kyphosis
fixed- cant straighten spine when standing straight
-due to abnormal vertebrae (scheuermanns kyphosis)
felxible- can straighten spine
