Spine Flashcards
Function of the spine
Protects the cord and nerves
Posture and locomotion
Supports BW above pelvis
Partial rigidity for head to pivot on
Back pain impact
8/10 affected
leads to most sick days
2nd most common reason for primary care visit
high cost to NHS
What are the pain producing structures
Nucleus pulposus, Annulus fibroses, Facet joints and Synovium of facet capsule, Ligaments, Muscles, Nerves, Meninges
Red flags for neck and back pain
> 50/ <20 yo
fever and night sweats
travel/ TB contacts
immune suppression
IVDU
Recent bact infection or surgical procedure
Morning stiffness
Saddle anaesthesia/ bladder/ bowel [cauda equina]
Sexual dysfunction, disturbed gait, progressive neuro deficits
Uncontrolled pain
Thoracic pain
Yellow flags for neck and back pain
Negative attitude, depression, social withdrawal
Fear avoidance and reduced activity levels
Belief that passive rather than active treatment will be beneficial
social/ financial problems
Masquaraders of neck and back pain
AAA, Renal (e.g. pyelonephritis)
NICE Guidelines (2018) Treatment for back pain
STaRT Back Screening Tool
Self-management advice
- Daily activity
- Cold/heat therapy
- psychological support
Medication
- NSAIDS (not paracetamol alone)
- Codeine as weak opioid
- Diazepam for muscle spams (Short course)
NICE Guidelines (2018) Treatment for back pain - SCIATICA
Neuropathic meds
- Amitriptyline, Duloxetine, Gabapentin
- Tramadol –> Acute rescue therapy
- Capsaicin cream (local)
+ NRB
+ Decompression surgery
Cord Compression
Cord, conus, or cauda
Causes:
- tumour/ lesions
- trauma
- spinal stenosis
- infection/ inflammation
Characteristics of acute cord compression
Above conus/ cauda UMN signs back pain > leg infection and Ca risk => Oncological/ orthopaedic emergency
Cauda Equina Syndrome
LBP + unil or bilat radicular pain saddle anaesthesia/ parasthaesia bowel dysfunct, loss of anal sphincter tone perianal/ perineal sensory losss bladder dysfunction, incontenence sexual dysfunction progressive neurological deficit
Mx: Surgical emergency - decompression
Cancer/ Infection
Night pain systemic Sx, fever, septic thoracic pain (DDx thoracic aneurysm) IVDU Hx of cancer or recent infection immunosuppression postural deformity point tenderness +/- neurology
Ix - MRI gold standard, plain radiograph to exclude fracture
Mx - Rx cause, Abx, Referral to ortho or oncology
Fracture
Severe pain - rest + night
Assess for risk factors e.g. osteoporosis, Ca
Specific sports - rowing => pars stress fracture, synchronised swimmers => sacral stress fracture
Mx - pain control by ortho, surgery if unstable/ deformity/ ongoing pain; vertebroplasty/fusion
Inflammatory causes of back pain
Medical acute back pain presenting with morning stiffness (>30min), common in young
insidious onset and chronic
other inflammatory features
Sacroilitis as initial presentation (MRI gold stand)
Ix:
- FABER (Patrick’s) test - positive with pain at hip, lumbar, sacroiliac joint
- Palpate SIJ
- Seronegative + bloods
- XR/ MRI
Mx: Rheumatology + NSAIDs
Facet Joint Pain
Discogenic!
Mostly lumbar +/- nerve root involvement
>35yo (degenerative changes)
Clinical Sx correlate image => adjust treatment
Acute Nerve Root Compression
Discogenic pain - due to acute disc prolapse or facet joint osteophyte
Unilateral radicular pain; leg pain > back
tingly/ weakness
aggravated by sneezing, coughing, heavy lifting
numbness, loss of reflexes
worse on flexion (NB facet worse on extension)
limp to contralateral side
O/E - SLR <30 degrees, Slump test positive, Acute muscle spasm on palpation
Mx
- Paracetamol and NSAIDs
- Codeine short course
- Benzos
- Amitriptyline, gabapentin [neuropathic]
- PT
Facet joint - Chronic
Older people due to degenerative changes aggravated by extension + lat flexion/ abduction \+/- nerve root Sx decreased ROM Tender to palpation
Ix - MRI gold stand, CT, Bone scan
Mx - Same for arthritis, Facet joint injection (diagnostic and therapeutic)
Facet Joint fracture types
1 - Dysplatic/ congenital 2 - Pars defect (lytic) 3 - Degenerative 4 - Traumatic 5 - Pathological secondary to bone disease
Pars Interarticularis Stress Fracture
Young athletes e.g. fast bowlers
Due to hyperextension and rotation
unilateral LBP
aggravated by movement especially extension
excessive lumbar lordosis and hamstring tightening
palpation unilateral tenderness
Ix
- Oblique radiograph: ‘scottie dog’ sign
- SPECT/ BONE SCAN
Mx - Relative rest, analgesia, PT, correction of technique
Spondylolisthesis
Most common at L5
Due to bilateral pars defect
Traumatic or congenital
LBP +/- leg pain; claudication if central stenosis
palpable dip
compensatory muscle spasm of hamstring
decreased ROM + increased lumbar lordosis
when L5 nerve in lat recess => weak EHL
Ix - Lateral XR; grade slippage (I-IV)
Mx - Relative rest, analgesia, PT, Grade III and IV => AVOID contact sports; If progresses then ortho referral
Lumbar Spinal Stenosis
Elderly
3 mechanisms of injury: central disc, ligamentum flavum hypertrophy, degenerative facets
LBP
Claudicant (neurogenic) - leans forward to relieve Sx
O/E Neuro - plantars, hoffmans, romberg
Mx - Surgical decompression +/- fusion, injection (for radicular; no epidural)
Torticollis (Wry Neck) - 2 types
Sudden onset neck pain, deformity, decreased ROM
Acute or chronic
Trauma, subluxed C1/2, drugs, osteomyelitis, retropharyngeal abscess, epiglottitis, epidural abscesses
Ix - XR/CT, bloods, referral
- Apophyseal*
- Young adults/ children => assess for trauma
- Acute
- C2/3 locking
- Mx: PT mobilisation and manipulation, analgesia
- Discogenic*
- Gradual/ after sleeping
- Most common
- C4-7
- Mx: self-resolve up to 4/52, analgesia, muscle relaxants, PT (NO manipulation)
Stingers/ Burners
Traction injury of the brachial plexus
Rugby tackle/ front row
Burning transient pain, paraesthesia, weakness
usually C5/6
recurrent
Full neuro exam
Mx - Self-resolved with hrs to days, immobilise if in doubt, no RTP until full resolvement
Scheuermann’s
Thoracic pain
adolescent males
thoracic kyphosis (e.g. computer games)
multiple end-plate irregularities in >=4 vertebral bodies
Masqueraders of thoracic pain
chest, cardiac, oesophagus
Other causes of back pain
degenerative scoliosis asolescent idiopathic scoliosis sacralisation of L5/ Labarisation of S1 (formation of pseudoarthrosis) Coccygeal pain Baastrups (kissing spine)
