Spinal Disorders - Clinical Medicine Flashcards
1
Q
What are the two main classifications of back pain? Provide examples for each one
A
- Non-inflammatory
- Mechanical/low back pain +/- sciatica
- OA
- Spinal stenosis
- Spondylolisthesis
- Scoliosis
- Vertebral fracture
- Inflammatory/serious pathology
- Infection e.g., discitis, osteomyeletits, abscess
- Axial spondyloarthropathy
- Malignancy
2
Q
Describe the terms/conditions involved in back pain
A
- Discogenic pain
- Degenerative disc disease
- Lumbar disc herniation
- Secndary to lumbar degenerative disease
- Facet joint pain
3
Q
Describe the epidemiology of mechanical pain
A
- Low back pain causes more disability, worldwide than any other condition
- Prevalence and burden of mechanial back pain increases with age until around 6th decade
- Prevalence of back pain is more common in women and increases with age, peaking around 7th decade
4
Q
Describe the principles of assessment of mechanical/low back pain
A
- Symptoms
- Assess if nerve root irritation is present
- Nerve root irritation tests
- Document neurological signs
- Exclude cauda equina syndrome
5
Q
a) Describe the clinical feature of mechanical back pain
b) What is the first line treatment of non-specific back pain according to the NICE guidlines?
A
a)
- 90% of all back pain is mechanical
- Exact causes rarely identifiable
- Lumbosacral, buttocks and thighs
- Pain worse towards end of day
- Patient is well
b) NSAIDs and PPI
6
Q
Describe the prognosis for mechanical back pain
A
- Good
- 50% of patients better withing a week
- 90% better within 6 weeks
7
Q
Describe the recureence of mechanical back pain
A
- 60% will have a recurrence within 1 year
- Recurrent attacks tend to settle within 3-5 years
- Peaks in middle decades and becomes less frequent in later life
8
Q
Describe the clinical features of nerve root pain
A
- Unilateral leg pain > back pain
- Radiation below knee
- Numbness and parathesia
- Nerve irritation signs
- Motor, sensory, or reflex change - limited to one nerve root
9
Q
Which nerve roots does 83% of prolapsed intervertebral discs involve?
A
- L5 (51%)
- S1 (22%)
10
Q
Which type of people does a prolapsed intervertebral disc at L3 or L4 affect? What is the percentage of this?
A
Elderly and 17%
11
Q
Describe the commonly affected nerve roots and the percentage of people it affects
A
- 83% of prolapsed intervertebral discs will involve L5 (51%) or S1 (22%) roots
- L5 and S1: 10%
- L3 or L4: 17% (usually elderly)
12
Q
Describe the motor signs of an L5 nerve root pain
A
- Weak dorsiflexion bigtoe
- Weak dorsiflexion lateral 4 toes
- Weak eversion
13
Q
Describe the motor signs of a S1 nerve root pain
A
- Absent ankle jerk
- Weak gluteal contraction*
- Weak knee flexion*
- Weak toe plantar flexion
* Occurs with absent ankle jerk
14
Q
Which muscle movement/movement affected will be caused by L2?
A
Hip flexion/adduction
15
Q
a) Which muscle movement/movement affected will be caused by L3?
b) State the tendon reflex decreased
A
a)
- Hip adduction
- Knee extension
b) Knee jerk reflex decreased
16
Q
a) Which muscle movement/movement affected will be caused by L4?
b) What tendon reflex is decreased?
A
a)
- Knee extension
- Foot inversion/dorsiflexion
b) Knee jerk
17
Q
Which muscle movement/movement affected will be caused by L5?
A
- Hip extension/abduction
- Knee flexion
- Foot/toe dorsiflexion
18
Q
a) Which muscle movement/movement affected will be caused by S1?
b) State the tendon reflex decreased
A
a)
- Knee flexion
- Foot/toe plantar flexion
- Foot eversion
19
Q
Describe the epidemiology of sciatica including the liftime incidence, annual incidense and age affected
A
- Sciarica has a lifetime incidence ranging from 13% to 40%
- The annual icidence of an episode s 1-5%
- The incidence is related to age - rarely seen before the age of 20, incidence peaks in the 5th decade and then declines
20
Q
Describe the modifiable risk factors associated with the 1st onset of sciatica
A
- Smoking
- Obestiy
- Occupation factors
- General health status
21
Q
Describe the prognosis of patients with nerve root pain
A
50% of patients with nerve root pain are better within 6 weeks - self-limiting
22
Q
Describe this MRI of the spine
A
23
Q
Describe the NICE recommendations for those with nerve root pain
A
- Examine patient
- Do not refer for investigations unless high risk of poor outcor
- Imaging in specialist setting of care if result is likely to change management
- Educate to self-manage and encourage normal acitivites
- Consider manual therapy (Spinal manipulation, mobilisation, or soft tissue technologies such as massage)
- Consider psychological approaches using cognitive behavioural approach with excercise, with or without manual therapy
- Consider oral NSAIDs and weak opiods (with or without paracetamol)
24
Q
What do NICE recommend that you should not for patient with nerve root pain
A
- Belts or corsets
- Foot orthotics or rocker sole shoes
- Traction (patient pulled so disc can go back in)
- Acupunture
- Ultrasounds, transcutaneous electrical nerve stimulation (TENS), interferential therapy
- Paracetamol alone, opiods, antidepressants, or anticonvulsants
25
Describe the NICE approved interventions for nerve root pain including how they work and their effectiveness
Radiofrequncy denervation - focused electrical energy that heats and denatures the nerve with relief at least 6-12 months
Epidural/nerve root injections - injection in epidural space of spine that takes down any inflammation around that nerve root
Spinal fusion - Fuses 2+ veretebrae together. No overall no clear advantage but do show some modest beneft for elemens of pain, function, and quality of life
26
Decsribe the difference between sacral epidurals vs nerve root blocks
Sacral epidural
* Needle goes through one of the holes in the sacrum and is injected with combination of local anesthetic and steroids - blind injection
Nerve root blocks
* Radiologist does CT and injects around inflamed nerve root
27
a) Why is physical activity recommeded for back pain?
b) Is the precise form of excercise important?
a)
* Rest peputates disability
* May relieve venoud congestion and oedema
* Muscular afferent activity may interfere with pain signal processing
* Spinal movement may have a similar effect
b) No
28
Describe the assessments undertaken for the 10% of people with back pains that doesn't get better after 6 weeks?
Biological assessment
* Nerve root probems
* Red flags
* Check CRP/L spine x-ray if relevant
Psychological assessment
* Unjustified fears?
* Depressed?
Social assessment
* Family relationship
* Work problems
29
List the risk factors for chronic back pain
* Previous history of back pain
* Previous time off work
* Radicular pain
* Unfit
* Poor general health
* Smoking
* Depression/ anxiety
* Disproportionate pain behaviour
* Personal problems
* Medicolegal proceedings
30
List red flags of back pain
* Malignancy
* Corticosteroids
* Patient systemically unwell
* Weight loss
* Widespread neurology
* Age \<20 years or \>55 years
* Violent trauma
* Constant, progressive, non-mechanical back pain
* Thoracic pain
* IV drug abuse/HIV infection
* Persisting severe restriction of lumbar flexion
* Structural deformity
31
a) What is Cauda equina syndrome?
b) Describe the presentation
c) What would you find on rectal examination?
d) What action needs to be taken if someone is suspected of corda equina syndrome?
a) Large central disherniation compressing the corda equina (also tumours/abscesses)
b)
* Bilateral sciatica
* Urinary/faecal incontinence
* Saddle anaesthesia
* Widespread (\>one nerve root) or weakness in legs
c) Rectal examination reveals reduced tone
d) Urgent MRI and spinal surgeon assessment
32
Describe the presentation of back pain due to osteoarthitis
* Pain is most pronounced in morning
* Pain recurs when joint has been stressed with excercise/weight-bearing
33
a) What is spinal stenosis
b) Describe the pathaphysiology of spinal stenosis (lumbar cancal stenosis)
c) Describe the epidemiology
d) Describe the presentation
e) What is the 1st choice investigation?
f) How will contradindications (body habitus, metallic implants) change the investigation?
g) Wht is the managment
a) A narrowing of the spinal canal in the lumar spine
b) Symptoms are thought to be due to local vascular compromise secondary to the canal stenosis, making the nerve roots ischaemic and intolerant of the increased demand on excercise
c) Elderly patient - due to OA of spine
d)
* Low back pain radiation to the legs with excercise
* Worst after extertion and standing
* Relieved by rest over 10 mins or so
* Relieved by bending forward (simian posture)
e) MRI as 1st choice
f) Contraindciations (body habitus, metallic implants) may make CT or myelography necessary
g) Lumbar laminectomy may provide relief of symptoms and recovery of normal excercise tolerance
34
a) What is spondylosis and what is it usually related to?
b) Describe the clinical presentation
c) What investigations should be undertaken?
d) Describe the treatment
a) Spondylosis describe the general degeneration to the spine.The defect is in pars intra-articular (a small segment of bone that joins the facet joints in the back of the spine) usually 5th nerual arch. It is related to sport in teenage years
b) Usually asymptomatic but can beaassociated with low back pain
c) Oblique plain radigraph and MRI if there are neurological symptoms
d) Treatmet is conservative
35
a) What is spondyliosthesis
b) What are the causes?
c) Describe the clinical presentation
d) What is the treatment
a) Spontaneous displacement of a verterbral body in relation to the vertebral body directly beneath it. Usually displaced in an anterior direction
b) Spondylosis, congenital malformation and facet joint OA
c) Sciatica and neruuolican involvement can occur (less likely with OA)
d) Treatment is conservative but spinal fusion is possible but rare
36
Describe the role of axial spondyloarthropathy is back pain
Involves synovitis and enthitis
Ossifcation of enthesis especially the spine
HLA B27 association
37
What are the types of spinal infection that can happen?
* Vertebral osteomyelitis
* Discitis
38
Describe the difference between verterbal osteomyelitis and discitis
Vertebral ostemoyleitis -infection of vertebra/spine
Discitis - infection within disc
39
a) How are spinal infections such as vertebral osteomyeleitis and spread? and commonly by which bugs?
b) Descibe the clinical features of spinal infection
c) What investigations should be undertaken?
a) Haematogenous spread and commonly by Staph auerus and coagulase negative staph
b)
* Insidious onset of pain
* Spinal tenderness
* 15% have symptoms and signs of nerve root compression
* Fever in less than 50%
c)
* Inflammatory markers
* Blood cultures
* whole spine MRI - as more than one level can be affected
* Blood culture biopsy yield of 50%
40
Describe this MRI and state you're differential diagnosis
Infection so osteomylelitis and/or discitis
41
Define referred pain
Referred pain is pain arising or ocurring in a region of the body, innervated by nerves other than those innervating source of pain
42
List the main regions activated in response to acute nociceptive stimulation
* Spinal cord
* Thalamus
* S1 and S2
* Insula
* Anterior cingulate cortex
* Preforental cortex
43
What is radicular pain?
Irrittation and inflammation of a spinal nerve root
44
Describe the involvement of the brain in radicular neuropathic pain
* Pathological activation neurones in dorsal root ganglion
* Nociceptor terminals not activated
* May involve irritation of all fibres: A-alpha (weakness), A-beta (sensory alteration), A-gamma (reflex loss), A-delta (pain), C (pain)
45
How is pain referred to dermatomes?
By direct activation of segmental nerve root
46
Describe the ways that an afferent noxious input to a certain spinal segment may refer to the dermatome
* Muscle via nociceptive affarents that run with motor nerve
* Joint via nociceptive afferents from joint structures
* Bone via periosteal nociceptive affernts
* Visceral input via visceral "SNS" autonomic fibres
47
What is the fundamental concept of referred pain
Dorsal horn convergence
48
a) What is referred radicular pain?
b) What are some causes of this?
a) Pain arising from pathological activation of the dorsal root ganglion at a spinal segmental level
b) Disc prolpase causing sciatica, degenerative compression/malignant infiltration of nerve roots
49
What is referred somatic pain?
Pathology in fibres from the nerve root that innervate spinal ligaments, facet joints, disc annulus etc (distal to the dorsal root ganglion) produce nociceptive input that converges in the dorsal horn with cutaneous sensory afferents
Pain can therefore be referred distally along the distribution of the nerve root
50
What is referred muscle (myofascial) pain
Nociceptive afferent activation within muscle converges in the dorsal horn of the sppinal cord at the same segmental level as the motor supply originates (in the ventral horn)
51
What is referred visceral pain?
Nociceptive afferents from the gut coalesce in the visceralplexi: coeliac, mesentric, hypogastric, renal etc. Afferent fibres run with the visceral autonmoic nerves
52
Why do patients with hip osteoarthitis get knee x-ray?
Both the knee and hip get innervation from T2, L1 (cutanous), L2,3,4 lumbar plexus (hip flexors/capsule), L5, 1 sciatic (acetabular)
53
Define Hilton's law
A nerve supplying a muscle controlling a joint also innervates the joint
54
55
Describe the red flags of cauda equina
* Bilateral sciatica
* Severe or progressive bilateral neurological deficit e.g., major motor weakness with knee extnsion, ankle eversion or foot dorsiflexion
* Difficutly initiating mictrution or impaired senstation of urinary flow (can be irreversible if left untreated)
* Urinary retention with overflow urinary incontinence
* Loss of sensation of rectal fullness (if untreated this may be irreversible)
* Faecal incontinence
* Perianal, perianal or genital sonsory loss (saddle anaesthesia or paraesthesia)
* Laxity of anal sphincter
56
Describe the red flags of a spinal fracture
* Sudden onset of severe central spinal pain which is relieved by lying down
* There may be a history of major trauma
* People with osteoporosis or those using corticosteroids
* Structural deformity of the spine
* There may be point tenderness over a vertebral body
57
Decsribe the red flags of a spinal infection
* Fever
* TB or recent UTI
* Diabates
* History of IV drug use
* HIV infection, use of immunosuppressants or the patient is immunocompromised
58
Describe the red flags of spinal malignancy
* 50+ years
* Gradual onset of symptoms
* Severe unremitting pain that remains when patient is supine, aching night pain that preventsor disturbs sleep, pain aggravated strainging e.g., at stool or coughing and thoracic pain
* Localised spine tenderness
* No symptomatic improvement after 4-6 weeks of conservative low back pain therapy
* Unexplained weight loss
* Past history of cancer- breast, lung, GI, prostate, renal and thyroid more likly to metastasise to the spine
59
Describe the components of the pain management jigsaw
* Interventions
* Medications
* Relaxation
* Complimentary therapies
* Excercise
* Neuromodulation
* Psychology
* Lifestyle changes/coping
60
Describe the yellow flags of chronic back pain
* Attitudes- towards current problem . Does the pt feel that with appropriate help and self-management they will return to normal activites?
* Beliefs - Misguided belief e.g., pt feels they have something serious causing their problems, usually cancer
* Compensation
* Diagnosis - Inappropriate communication can lead to pts misunderstanding
* Emotions - pts with other emotional difficulties e.g., depression are at high risk of developing chronic pain
* Family - families can be over-bearing or under supportive
* Work - the worse the relationship, the more likely they are to develop low back pain
61
Describe how to get patients to excercise whilst having persistent pain
* Patient education
* Goals and education
* Look at function/meaningful activities
* Parameters of excercise - stretching, strength, aerobic
* Start with an achievable level
* Gradual increments - (0-20%)
62
Describe the different factors affecting chronic pain and provide with examples
Psychological/emotional
* Impact on mood
* Low mood
* Depression
* Anxiety
* Anger
* Irritability
* Changes in role
* Loss of independance
Physical function
* Mobility and reduced activity
* Fitness
* Sleep disturbance
* Fatigue
* Changes in appetite
* Changes in weight
* Sexual function
* Medication side effects
Social/relationships
* Diminished relationship
* Impact on initimate relationships
* Decreased recreational activities
Societal
* Work/education
* Increased health care use
* Possible substance misuse, increase use of alcohol
63
Describe the association between chronic pain and mental health
* Pain can affect mental health issues, but mental health can exacerbate pain and associated with poorer outcomes
* Depression and anxiety reported in at least 20-50% of chronic pain sufferers
* Pain patients are at greater risk of completed suicide
* Substance misuse in pain populations greater compared to the general population
* More likely to have lower wellbeing scores
* High co-morbidity between PTSD and chronic pain
64
What is pain management all about?
* Improving function/QoL
* Helping people to learn how to manage their experience of pain and associated emotional distress in more helpful and productive waye
* Not about 'curing' pain
* Emphasizes message that they are not helpless in dealing with their pain and it should not control their lives
* Helping them to take a moreactive approach to managing their pain
65
What are the psychological models in pain managment?
1. Behavioural therapies
* Classical conditioning (paired association)
* Operate condition - positive and negative reinforcement
2. Cognitive behaviour therapy
66
Describe the use of ACT for chronic pain
* Not about reducing pain
* Focus on changing behaviour rather than changing thoughts and feelings
* Uses acceptance and mindfulness skills
* Teaches psychological skill sto deal with the painful thoughts and feelings efectively
* Aims:
Help patients live a fulfilling life
Increase awaresness of reaction to internal and external experience and how these can impact behaviours
Increases openess and willingness to experience these difficult experiences
In the service of engaging with doing what matters to us
67
Describe the difference between cognitive behaviour therapy (CBT) and acceptance and commitment therapy
68
What are the issues with using medication for chronic pain?
* In the absence of red pathology, very little evidence for benefit of medication for back pain
* High risk of long-term dependance with short acting opiates
* Anti-inflammatory may benefit short term use
69
Describe the pain managment program
* Gold standard of non-interventional pain managment
* Patients offered 10 x 3.5 hrs sessions
* Timetable inculdes a weekly practical excercise session, a reveiw of personal value-based goals and a psychology session
* Qualitative outcomes focuses on patient's own values and goals - often related to hobbies, relationships, or practical gains rather than reduction in measured/VAS pain scores
70
What is iatrogenic analgesia addiction
The development of narcotic dependance following medical treatment
71
Describe the different management of iatrogenic analgesia addiction
* Substituion therapy, in which a replacement medicinal grade drug
* Facilitating drug withdrawal (detox) - by substituting a drug in the same class where the withdrawal is less intense or by administration of other drugs during the withdrawal process that reduce intensity of the withdrawl symptoms
* Blocking the effects of the abused drug - by prior administration of an antagonist so that if the individual detoxed but relapses and reatkes the drug again, they will not experience the pleasurable effects of the drug
* Blocking the effects of an abused drug immunisation to produce circulating antibodies
* Making the drug experience unpleasant
* Reducing craving for the drug
72
What situations inolving the spine do surgeons operate on?
* Trauma
* Degenerative conditions
* Infections
* Deformities
* Tumours
73
1. If there has been spinal trauma what should you do
a) ASAP
b) If pain is still there at 6 weeks
c) At 3 months
2. What is your suspected diagnosis if there low energy trauma resulting in neck pain in elderly and what is required?
1. a) X-ray for suspected osteoporotic fracture ASAP
b) MRI if pain at 6 weeks
c) Vertebroplast by 3 month
2. Cervical fracture and a CT scan is required
74
What are the triad of epidural abscess?
* Fever
* Back pain
* Neurological defecit
75
a) List some example of degenerative spinal conditions
b) Who are they more common in?
a)
* Claudication
* Spinal stenosis
* Disc prolapse
* Spondyliothesis
* Sciatica
b) Female - average age 64
76
List some reasons for spinal reoperation
* Sagittal balance problems
* Metal work
* Impingement on nerve roots
* Psuedoarthrosis and failure
* Infection
77
What are the non-surgial treatments of the spine?
* Injections
* Ablation
* Cord stimulation
78
List the new fixation techniques
* Minimally invasive spine surgery
* Endoscopic spine surgery
* Computer navigated spine surgery
* Robotic spine surgery
79
List some of the co-morbidies of spinal degenrative conditions
* Hypertension
* Osetoarthritis
* RhA
* Diabetes mellitus
80
Amitriptyline (tricyclic antidepressant)
a) Indications
b) Initial and maximum dose
c) Cautions (inc.renal and hepatic)
d) Most important side effects
e) Special considerations
a) Neuropathic pain, migrains, irratible pain syndrome, fibromyalgia, insomnia (previously used as antidepressant dose 100-150mg)
b) Initial 10-20mg at night
Maximum:any dose above 100mg should be used with caution. Cannot increase more than 25mg
c) Caution in mild to moderate renal imapirment and cardiovascular disease
d) Drowsiness, constipation, dry mouth, urinary retention, anticholinergic (especially if co-prescribed with other anticholinergic medications in older patient- confusion, delirium, sedation. urinary retention etc)
e) Take at night due to drowsiness, toxic in overdose
81
Diazepam (benzodiazepine)
a) Indications
b) Initial and maximum dose
c) Cautions (inc.renal and hepatic)
d) Most important side effects
e) Special considerations
a) Acute muscle spasms, anxiety (status epilepticus)
b) Initial: 2mg TDS and can be increased to 5mg TDS orally.
Maximum: 60mg daily
c) Avoid in severe hepatic impairment, reduce dose in renal impairment, patients known for drug abuse
d) Drowsiness, change in behaviour, slows down respiratory rate
e) Caution with alcohol and opiods (reduces respiratory rate), counsel patients not to drive if drowsiness, controlled drug as it can be misued. Taper if taking for any length of time to avoid withdrawal symptoms
82
Gabapentin (gabapentinoid)
a) Indications
b) Initial and maximum dose
c) Cautions (inc.renal and hepatic)
d) Most important side effects
e) Special considerations
a) Neuropathic (epilepsy)
b) Initital: 300mg OD day 1, 300mg BD day 2, 300mg TDS day 3 (may want to go much slower especially in older patients)
Maximum: 3.6g total daily dosage
c) Reduce dose according to renal function
d) Unsteady (ataxia), drowsiness, cofused, anxiety, abnormal appetite, dizziness, depression, weight gain oedema
e) Caution with alcohol and opiods (reduces respiratory rate), counsel patients not to drive if drowsiness, controlled drug as it can be misued. Taper if taking for any length of time to avoid withdrawal symptoms
83
Pregablin
a) Indications
b) Initial and maximum dose
c) Cautions (inc.renal and hepatic)
d) Most important side effects
e) Special considerations
a) Peripheral and central neuropathic pain (epilepsy and anxiety)
b) Initial: 25mg BD po
c) Respiratory depression, renail failure, in anything else that surpresses the nervous system
d) Increased suicidal feelings, dizziness, drowsiness, unsteadiness, GI side effects
e) Caution with alcohol and opiods (reduces respiratory rate), counsel patients not to drive if drowsiness, controlled drug as it can be misued. Taper if taking for any length of time to avoid withdrawal symptoms
