Spinal Conditions Flashcards
Mechanical back pain - clinical features
Pain in lower back, buttocks and thigh
- rarely below knee
Worse over the course of the day and with activity
Wakes from sleep on movement
Settles with rest
Pain midline and worsened by lordotic postures
- e.g. bending and lifting
Mechanical back pain - anatomy causing the pain
Annulus fibrosis layer of the disc causes pain when it is stretched
Mechanical back pain - management
Initial - bed rest
Analgesia - NSAIDs best
- paracetamol, muscle relaxants, opioids
Early mobilisation - especially mild/moderate pain
Ice and heat
- 2 or 3 times a day for 20 mins
PT - massage, acupuncture and hydrotherapy
Counselling
Psychological support
Surgery (rare, only in severe cases)
- spinal fusion
Nerve root impingement - clinical features
Pain - radiates down leg from buttocks to calf/foot (matches sensory dermatome of affected nerve root) - on sneezing, coughing and straining - spinal stenosis: worse on extension, relieved by flexion Paraesthesia over affected dermatome Loss of tendon reflex - knee (L3/4) - ankle (L5/S1)
Nerve root impingement - causes
Lumbar disc prolapse - compresses and irritates the nerve root as it exits the spinal foramen
Spinal stenosis
Osteophytic nerve root compression
Infection e.g. herpes zoster
Failed back surgery syndrome
- e.g. arachnoiditis, epidural adhesions and recurrent herniation
- can also cause mechanical back pain
Nerve root impingement - management
Non-operative - same as mechanical back pain
- 2nd line: selective nerve root corticosteroid injections
Surgery
- discectomy
- laminectomy (for both spinal and nerve root decompression)
- chemonucleolysis/percutaneous disc removal
Red flags for back pain
Infection - IVDU/immunosupression, fever/chills and recent significant illness or infection Tumour - weight loss, signs and symptoms of spinal compression and history of malignancy History of trauma Cauda equina signs and symptoms Age <16 years or >50 years Long-standing steroid use Hip/knee weakness Generalised neuro deficit Non-mechanical pain (worse at rest) Thoracic pain Reduced anal tone Progressive spinal deformity Night pain
Serious spinal pathologies
Tumour
Infection
Trauma
Inflammatory conditions
Spinal tumour - causes
Malignant spinal cord compression
- primary
- metastatic
Spinal tumour - investigations
Bloods
- FBC, ESR, LFTs, calcium, phosphorus, ALP
- basic metabolic panel( U&Es, glucose)
Serum and urine immunoelectrophoresis
Imaging
- Spinal X-Ray (AP and lateral)
- CT - AP and chest
- MRI - in under 24 hours for spinal compression
Biopsy
- when primary carcinoma not identified, needed to rule out primary bone tumour
Spinal tumour - onward referral pathway
Urgent referral - for known cancer and early presentation - initial referral to neurosurgery - referral to oncology - involve palliative care Urgent referral - patient no cancer - neurosurgery - oncology once malignancy confirmed Non-urgent referral - patient with known cancer - care at home/MDT package - palliative care
Spinal infection - discitis clinica features
Severe back pain - loss of mobility/changes in posture Fever Back stiffness Abdominal pain/discomfort Loss of appetite
Spinal infection - investigations
MRI - BEST X-Ray takes 1 week for symptoms to manifest Bloods - CRP and WCC Tissue sampling Bone scan Blood cultures
Spinal infection - signs on X-Ray
Disc space narrows
Endplate erosion
Loss of lumbar lordsis
Spinal infection - treatment
Non-operative
- bed rest and immobilisation
- antibiotics (4-6 weeks) - IV for S.aureus for the first week, before conversion to oral
Operative
- used if abscess or thecal sac displacement
- surgical debridement followed by antibiotic treatment and bracing
