Spinal disorders Flashcards
Epidemiology of mechanical backpain
- more common in women
- 80% of people experience mechanical back pain
- Onset = 20-55yrs
What are the clinical features of back pain
- systemically well
- pain worse towards end of day
- pain in lumbosacral area, buttocks and thighs
Prognosis of mechanical back pain
- good
- 90% get better within 6 weeks
- 50% get better within one week
- 60% tend to get a recurrence within 1 year
What are the features of nerve root pain?
- unilateral leg pain more than back pain
- radiates below the knee
- nerve irritation signs
e.g ightheadedness.
Dry eyes and mouth.
Constipation.
Bladder dysfunction.
Sexual dysfunction - Motor, sensory or reflex change (limited to one nerve root)
Which nerve root tends to have prolapsed intervertebral discs?
- L5 (51%)
- S1 (22%)
What are the motor signs of L5
Weak dorsiflexion of big toe
Weak dorsiflexion of lateral 4 toes
weak eversion
Motor signs of S1
absent ankle jerk weak gluteal contraction weak knee flexion weakness toe plantar flexion (do not occur without absent ankle jerk)
Epidemiology of sciatica
- annual prevelance 1-5%
- rarely seen before the age 20
- incidence peaks in 5th decade then declines
Modifiable risk factors of sciatica
- Smoking
- Obesity
- Occupational factors
- General health status
What is sciatica?
Leg pain secondary to lumbosacral nerve root pathology
What are the nice recommendations for patients with back pain?
Imaging in a specialist setting
Examine patient
Consider group exercise programme
Educate to self- manage their low back pain & encourage to continue normal activities
Consider manual therapy e.g spinal manipulation, mobilisation or soft tissue techniques such as massage
Weak opiods
Consider NSAIDS
What are against nice guidelines regarding managing back pain
- belts or corsets
- foot orthotics or rocker sole shoe
- acupuncture
- traction
- only paracetamol, antidepressants or anticonvulsants
Interventions for backpain (surgical)
- Radiofrequency denervation: focused electrical energy heats and denatures the nerve
> provides relief for at least 6-12months
Epidurals/nerve root injections
Spinal fusion: can improve QoL
Chronic pain risk factors
Previous history of back pain
Unfit
Poor general health
Smoking
Depression/anxiety
Disproportionate pain behaviour
Personal problems
Previous time off work
Red Flags in Back Pain
- Malignancy
- Corticosteroids use
- Pt systemically unwell
- Weight loss
- Widespread neurology
- Age < 20 yrs or >55yrs
- Violent trauma
- Thoracic pain
- IV drug abuse/ HIV infection
- Structural deformity
etc.
How does physical activity help with back pain?
- rest perpetuates disability
- could relieve venous congestion and oedema
- muscular afferent activity might interfere with pain signal processing
Clinical features of Cauda Equina Syndrome
- lower back pain
- sciatica
- numbness in legs
- bilateral leg pain
- loss of bowel control
- loss of urinary retention and haematuria
- saddle area numbness
Causes of Cauda Equina Syndrome
- bleeding
- trauma
- IV disc prolapse
Investigations and management of Cauda Equina Syndrome
Investigation:
Emergency MRI
Treatment
- Discectomy
- Stabilisation and fusion of vertebrae
What is the cauda equina syndrome?
- Nerve roots compression from L1/L2 down to sacral roots
What is spinal stenosis
Narrowing of spinal canal and can cause compression of nerve roots
How do you do a bio psychological assessment?
- Look for red flags
- Take a thorough history
- PMD and procedures/treatment etc
- Medical Regime - benefits? Side effects?
- Look for yellow flags
What do plain radiographs of spinal conditions show?
- information is readily available
- provides structural information: vertebral collapse, spondyloisthesis, scoliosis
- it is INSENSITIVE to EARLY DISEASE
What is the DEXA scan and name some features of it
- Dual energy X-rays
- Shows different absorption by bone
- compares it with a population data set
- it is dependent on bone density
- DOENST GIVE ANY INFORMATION ABOUT OTHER DISEASE PROCESSES
What are the features of a Nuclear Medicine Bone scan (PET SCAN)
- It is a functional scan
- it is sensitive but not specific
- emits radiation
What are the advantages of CT scans for spinal imaging?
- widely available
- access for people who cannot have an MRI scan
What are the disadvantages of CT scan?
- radiation
- falsely reassuring
When is imaging required for people with lower back pain?
- if LBP is persistent
- used to exclude sinister pathology e.g malignancy, infection and vertebral collapse
Who should not have MRI scans?
- patients that have internal metal sutures, shrapnel internally, plates, screws etc.
When is low back pain considered persistent?
> 6 weeks
What are limitations of plain film radiographs when imaging back pain?
- insensitive to early stages of disease
- to be able to visualise destructive lesions, at least 80% of medullary bone has to be gone
- it is unable to distinguish between chronic and acute vertebral compression fractures
Limitations of plain film radiographs
- might miss acute pars fractures particularly in the pre-fracture state
- high radiation dose
What imaging method is preferred to investigate spinal diseases?
- MRI scans
What are some things that would be detected by a MRI scan of the spine, that would not by a plain film
- acute pars stress oedema
- early spondylo-arthropathy
- neurogenic tumours
When should special investigations of spinal conditions start?
- within 18 weeks
- ideally after the physical examination
- and after treatment
What is vertebroplasty?
- involves injecting polymethylmethacrylate (PMMA) cement into collapsed vertebral body
What is kyphoplasty?
- employs a balloon tamp to create a cavity in a vertebral body and to restore vertebral body height
What are vertebral compression fractures secondary to?
- Osteoporosis
- Osteolytic metastases
- Multiple myeloma
- Vertebral haemangioma
What is flat back syndrome
- loss of ability to compensate for thoracic kyphosis by increasing lumbar lordosis
What are some complications of crush fractures?
- Pain
- Deformity
- Mortality
- Reduced pulmonary function
- Impaired functional status
- QoL
What is radiofrequency tumour ablation
- ablation method for small tumours
- high energy radio waves are inserted into the tumour
- this is done by the insertion of a thin needle- like probe into the tumour through the skin
- heat destroys the tumour
What are facet joint injections
- minimally invasive procedure
- ## physician inserts small amount of local anaesthetics in the facet joint to improve the pain
What is fluoroscopy?
A from of real time x-ray/CT that is used to guide the placement of the needle into the facet joint
What are peri- neural injections
- also known as nerve root block/injection
- relieves pain by delivering anti-inflammatory medication to an inflamed nerve
What is a lumbar discography
injection that helps doctors to locate a painful disc before performing a lumbar fusion surgery in patients whose pain didn’t improve with conservative treatment
Back pain is a diagnosis. TRUE OR FALSE
False- it is only a description of patients symptoms
Cauda equina syndrome red flags
- Bilateral sciatica
- Difficult urinary retention
- Faecal incontinence
- Perianal, perineal and genital sensory loss
- Severe or progressive bilateral neurological defect of the legs such as motor weakness with knee extension
Spinal fractures red flags
- sudden onset of severe central spinal pain (relieved by lying down)
- history of major trauma
- people with osteoporosis
- use of corticosteroids
Infection red flags
especially if CRP and WCC are raised
- fever
- TB
- Diabetes
- History of intravenous drug use
- HIV infection
- Use of immunosuppressants
Management in absence of long term antibiotics is not associated with a good outcome. TRUE OR FALSE
FALSE
it is associated with a good outcome
Malignancy red flags
- being >50 years
- gradual onset of symptoms
- severe unremitting pain when the person is supine
- localised spinal tenderness
- unexplained weight loss etc.
- history of cancer
Is there always a pathological process for back pain?
No - BACK PAIN is the leading cause of disability worldwide
What is the epidemiology of low back pain in the UK?
16% Of women
11% of men
What is the difference between disease and illness ?
Disease - objective biological event that involves disruption of specific body structures/organ systems caused by pathological or physiological changes
Illness- subjective experience or self- attribution that a disease is present (yields physical discomfort)
What does pain at the back of the thigh mean, (when the leg is stretched during a spinal examination)
Hamstring muscle pain
What does a shooting pain down the leg indicate?
Sciatica
How would you test for sensation (spinal exam)
Go over the dermatomes on the skin with a cotton wool 15-20 times to ensure you have been over all the dermatomes
You can also do a neurotip procedure but it involves a needle (Not required for year one)
What are yellow flags
Yellow flags are pyschosocial factors shown to be indicative of long term chronicity and disability: A negative attitude that back pain is harmful or potentially severely disabling
What are some yellow flags in back pain patients
- Attitude - does the patient feel that with the appropriate help and self management they will return to normal activities?
- Beliefs - e.g a feeling that something serious is causing their problems
- Compensation - is the patient awaiting payment for an accident etc?
- Emotions
- Family - e.g over or under bearing support
- Diagnosis - inappropriate communication can lead to patients misunderstanding what is meant
What is the role of physiotherapists when managing people with back pain?
- educating patients on how their muscles, back etc work
- try to pick out what patients meaningful activities are
- get them to understand what their achievable activities are
-
Psychological side effects of pain
-low mood
depression
loss of independence
irritability
anxiety
anger
Social side effects of pain
- diminished social life
- impact on intimate relationships
- decreased recreational activities
Physical function side effects of pain
- reduced mobility
- reduced fitness
- sleep disturbances
- fatigue
- changes in appetite
- changes in weight
- sexual function
- medical side effects
Societal side effects of pain
- affects work/education
- increased health care use
- misuse of substances & increased alcohol intake
What is denervation
Damage to peripheral nerves
What happens if the upper motor neurones get damaged
- Causes spasticity (tight or stiff muscles)
- however peripheral nerves remain normal
What is the function of the upper motor neurone
e motor system that is confined to the central nervous system (CNS) and is responsible for the initiation of voluntary movement and muscle tone (amount of tension in a muscle)
What happens when the sensory neurones get damaged
loss of sensation
What are the broad division of sensory neurones
Discriminative touch - ability to distinguish subjects, shapes, surfaces with fingers (information rely by large myelinated nerve fibres
Pain and temperature (small and thin, unmyelinated nerve fibres rely the information)
Patterns/signs of denervation
- loss of function in root distribution
- loss of function in distribution of named nerve
What are the two elements in the spinal nerve (structural elements) that cause significant problems = denervation
Pathology of myelin (made of Schwann cells)
Damage to axons
What causes damage to axons/ denervation
Direct injury
- compression (common, e.g ulnar nerve compression at elbow)
- transection
- stretching
Diseases (peripheral neuropathy)
- diabetes, b12 deficiency
- inflammation, autoimmune conditions
- infection, HIV, leprosy
- drugs and toxins
- inherited
How are peripheral neuropathies described
Length dependent - denervation and loss of function in a length dependent manner (affects the most distal parts of the body - starts at the feet and works it way up)
Non length dependent
(patchy process, can affect long and short nerves, usually caused by inflammatory conditions)
Mono neuropathy
- named nerve that is damaged e.g median nerve at wrist
Radiculopathy
- damage is at the root
What is axonotmesis
Damage to axon (only a few axons damaged)
- can recover but slow and may be incomplete
What is a neurotmesis
- complete transection of a nerve
- recovery requires grafting transection
- recovery requires axon regrowth - usually 1mm/day
What is a medical condition called that causes axon loss
Peripheral neuropathy
How long does it take for myelin to reform?
approx. 3 months
What is neuropraxia
- implies damage to a nerve in the form of myelin (temporary)
What does demyelination cause?
- slow conduction
- conduction block
What is wallerian degeneration
occurs after axonal injury in both the peripheral nervous system (PNS) and central nervous system (CNS).
What are the effects of motor nerve denervation
- atrophy (reduction in size of a cell, organ or tissue)
(neuromuscular junction builds the muscle - without it = muscle wastage) - weakness
-paralysis
What are the effects of sensory nerve denervation
- numbness
- pain
- paraesthesia
Effect of denervation in muscles
- start to generate spontaneous motor activity
e. g cramps, fibrillations and fasciculation - muscles remain viable for up to 2 years without a nerve supply after which they fibrose and cannot return to normal function
