Spine and upper limb

Question 1

What is mechanical back pain?

Answer 1

This can be thought of as recurrent relapsing and remitting back pain with no neurological symptoms. The pain is worse with movement (mechanical) and relieved by rest. Patients tend to be between the age of 20 and 60 and have had several previous “flare‐ups”. No “red flag” symptoms are present.

Question 2

What are the causes of mechanical back pain?

Answer 2

Causes implicated include obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis. Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.

Question 3

What is the treatment for mechanical back pain?

Answer 3

Treatment involves analgesia and physiotherapy. Patients should be reassured that they do not have a serious problem and should be urged to maintain normal function and return to work early. Bed rest is not advised as this will lead to stiffness and spasm of the back which may exacerbated disability.

Question 4

What are the red flag symptoms for back pain?

Answer 4

Non – mechanical pain

Systemic upset

Major, new, neurological deficit

Saddle anaesthesia +/- bladder or bowel upset

Back pain in <20yr old

New back pain in >60yr old

Systemic upset

Question 5

What type of back pain is characteristically worse on coughing?

Answer 5

Acute disc tear (discogenic back pain)

Question 6

What is the cause and treatment of an acute disc tear?

Answer 6

An acute tear can occur in the outer annulus fibrosis of an intervertebral disc which classically happens after lifting a heavy object (eg lawnmower). The periphery of the disc is richly innervated and pain can be severe.

Pain is characteristically worse on coughing (which increases disc pressure).

Symptoms usually resolve but can take 2‐3 months to settle.

Analgesia and physiotherapy are the mainstay of treatment.

Question 7

What is sciatica?

Answer 7

The gelatinous nucleus pulposis herniates/prolapses through a disc tear and impinges on a nerve root
-this most common happens in the lower lumbar spin with the L4, L5 and S1 nerve roots contributing to the sciatic nerve
=pain in the sensory distribution of the sciatic nerve

Question 8

How is sciatic pain different from mechanical back pain?

Answer 8

sciatica is a neuralgic pain that radiates to below the knee

• positive sciatic stretch test
• cross-over sign

Question 9

What clinical features are seen in:

• L3/4 prolapse
• L4/5 prolapse
• L5/S1 prolapse

Answer 9

L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk

L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior

L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks

Question 10

What is the first line treatment for sciatica?

Answer 10

First line treatment is with analgesia, maintaining mobility and physiotherapy.

Occasionally drugs for neuropathic pain (eg Gabapentin) can be used if leg pain is particularly severe. The majority of cases are dealt with in primary care with around 80‐90% of disc prolapses recovering spontaneously by 3 months.

Question 11

When is a discectomy indicated?

Answer 11

Very occasionally surgery (discectomy) is indicated when pain is not resolving despite physiotherapy and there are localising signs suggesting a specific nerve root involvement and positive MRI evidence of nerve root compression.

Evidence of secondary gain (compensation claim, disability benefit) or psychological dysfunction is usually a predictor of poor outcome of surgery and a contra‐indication. Discectomy has a small risk of permanent neurologic injury (less than 1%).

Question 12

How can bony nerve root entrapment occur?

Answer 12

OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica as previously discussed.

Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates.

Question 13

What is spinal stenosis?

Answer 13

With spondylosis and a combination of bulging discs, bulging ligamentum flavum and osteophytosis, the cauda equina of the lumbar spine has less space – known as spinal stenosis ‐ and multiple nerve roots can be compressed / irritated.

Question 14

What clinical symptoms are seen with spinal stenosis?

Answer 14

Sufferers tend to over 60 and characteristically have claudication (pain in the legs on walking).

However, in contrast to vascular claudication (from PVD):

• the claudication distance is inconsistent
• the pain is burning (rather than cramping)
• pain is less walking uphill (spine flexion creates more space for the cauda equina)
• pedal pulses are preserved

Question 15

How is spinal stenosis managed?

Answer 15

if symptoms fail to improve with conservative management (with physiotherapy and weight loss, if indicted) and there is MRI evidence of stenosis, surgery may be performed (decompression to increase space for the cauda equina) to help alleviate symptoms.

Question 16

What is cauda equina syndrome?

Answer 16

Occasionally a very large central disc prolapse can compress all the nerve roots of the cauda equina producing a clinical picture known as cauda equina syndrome. This is a surgical emergency as affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination. Prolonged compression can potentially cause permanent nerve damage requiring colostomy and urinary diversion and urgent discectomy way prevent this catastrophe. Symptoms and signs of cauda equina syndrome are one of the “red flags” of the spine which signify serious underlying pathology requiring urgent management.

Question 17

What are the clinical symptoms of cauda equina syndrome?

Answer 17

Patients usually have bilateral leg pain, paraesthesiae or numbness and complain of “saddle anaesthesia” – numbness around the sitting area and perineum.

Altered urinary function is typically urinary retention but incontinence can also occur. Faecal incontinence and constipation can also occur.
(DO A PR)

Question 18

what is the management of cauda equine syndrome?

Answer 18

Urgent MRI is required to determine the level of prolapse and urgent discectomy is required once the diagnosis is confirmed. Even with prompt surgical intervention, significant number of patients have residual nerve injury with permanent bladder and bowel dysfunction.

Question 19

What symptoms are commonly experienced with cervical spondylosis? what is the treatment?

Answer 19

Patients will complain of slow onset stiffness and pain in the neck which can radiate locally to shoulders and the occiput. Physiotherapy and analgesics are the mainstay of treatment.

Question 20

Which arthritis type can cause cervical spine instability?

Answer 20

Rheumatoid:
-atlanto‐axial subluxation can also occur due to destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament.

Question 21

What is impingement syndrome?

Answer 21

This is a syndrome where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement producing pain.

Typically the patient has a painful arc between around 60 to 120 degrees of abduction (these values are variable) as an inflamed area of supraspinatus tendon passes though the subacromial space.

Question 22

What are three causes of impingement?

Answer 22

Tendonitis Subacromial bursitis

Acromioclavicular OA with inferior osteophyte

A hooked acromion Rotator cuff tear

Question 23

What is the treatment for impingement syndrome?

Answer 23

Treatment is conservative in the first instance with the majority of cases settling with NSAIDs, analgesics, physiotherapy and subacromial injection of steroid. Up to 3 subacromial injections may be required.

Question 24

What is the second line treatment of impingement?

Answer 24

Cases which do not improve with these interventions may benefit from subacromial decompression surgery to create more space for the tendon to pass through.

Question 25

A patient presents with a story of:
a sudden jerk (eg holding a rail on a bus which suddenly stops) in a patient >40 years of age, with subsequent pain and weakness.
what do you think?

Answer 25

rotator cuff tear
-The tendons of the rotator cuff can tear with minimal or no trauma as a consequence of degenerate changes in the tendons

Question 26

What is the nature of the tear seen in rotator cuff tears? how are tears confirmed?

Answer 26

Tears can be partial or full thickness and usually involve suprapinatus.

Large tears can extend into subscapularis and infraspinatus.

Weakness of initiation of abduction (supraspinatus), internal rotation (subscapularis) or external rotation (infraspinatus) may be detected and wasting of supraspinatus may be seen.

Tears are confirmed on Ultrasound or MRI.

Question 27

what is the non-operative treatment for rotator cuff tears?

Answer 27

Non-operative: Many patients do well with physiotherapy to strengthen up the remaining cuff muscles which can compensate for the loss of supraspinatus. Subacromial injection may help symptoms.

Question 28

What is the operative treatment for rotator cuff tears?

Answer 28

Rotator cuff repair (open or arthroscopic) with subacromial decompression can be performed in an attempt to improve/maintain strength and to prevent subsequent arthritis from chronic cuff deficiency. However, the tendon is usually diseased and failure of repair occurs in around a third of cases. Very large tears may be irrepairable and the tendon may be retracted too far.

Question 29

What is adhesive capsulitis?

Answer 29

A disorder characterized by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months.

Question 30

Describe the natural history of adhesive capsulitis

Answer 30

Patients will initially complain of pain, which will subside (after around 2‐9 months) as stiffness increases (for around 4‐12 months) and then the stiffness gradually “thaws” out over time, usually with good recovery of shoulder motion. The principal clinical sign is loss of external rotation (along with restriction of other movements) which can also occur in OA, however OA tends to affect older patients.

Question 31

Adhesive capsulitis:

-who is more prone?

Answer 31

• diabetics
• hypercholesterolaemia
• dupuytrens disease

Question 32

what is the treatment of adhesive capsulitis?

Answer 32

Treatment in the majority of cases is non-operative with the aim of relieving pain and to prevent further stiffening while the condition resolves naturally.

Physiotherapy and analgesics help.

Intra‐articular (gleno‐humeral rather than subacromial) injections can help in the painful phase.

Once the pain has settled, if the patient cannot tolerate functional loss due to stiffness, recovery can be hastened by manipulation under anaesthetic (MUA which tears the capsule) or surgical capsular release (usually done arthroscopically) which divides the capsule leading to improved motion.

Question 33

What is acute calcific tendonitis?

Answer 33

This condition results in the acute onset of severe shoulder pain and is characterized by calcium deposition in the supraspinatus tendon which is seen on xray just proximal to the greater tuberosity

Question 34

What is the treatment for acute calcific tendonitis?

Answer 34

Great relief of pain is achieved with subacromial steroid and local anaethetic injection. The condition is self‐limiting with pain easing as the calcification resorbs.

Question 35

What causes traumatic shoulder instability? what can this lead to? when is treatment needed and what is done?

Answer 35

Patients can experience a traumatic anterior dislocation which after reduction may settle and the shoulder stabilizes with rest and a physiotherapy strengthening programme.

Some shoulders do not stabilize and develop recurrent dislocations or subluxations, often with minimal force. Age at time of first dislocation predicts the likelihood of further dislocations with 80% re‐dislocation rate in under 20s and 20% re‐dislocation rate in over 30s.

With recurrent dislocations in this group, a Bankart repair (open or arthroscopic) can stabilize the shoulder by reattaching the labrum and capsule to the anterior glenoid which was torn off in the first dislocation.

Question 36

what causes atraumatic shoulder instability?

Answer 36

Patients with generalized ligamentous laxity (idiopathic, Ehlers‐Danlos, Marfan’s) can have pain from recurrent multidirectional (anterior, posterior or inferior) subluxations or dislocations. Treatment is difficult as soft tissue procedures may not work.

Question 37

What causes carpal tunnel syndrome?

Answer 37

• most cases are idiopathic
• rheumatoid arthritis
• fluid retention (pregnancy/diabetes/CKD/hypothyroidism)
• wrist fractures

Question 38

What is the presentation of carpal tunnel syndrome?

Answer 38

Patients will present with parathesiae in the median nerve innervated digits (thumb and radial 2½ fingers) which is usually worse at night, loss of sensation and sometimes weakness of the thumb or clumsiness in the areas of the hand supplied by the median nerve. On examination there may be demonstrable loss of sensation and/or muscle wasting of the thenar eminence (with chronic sever cases). Symptoms can be reproduced by performing Tinel’s test (percussing over the median nerve) or Phalen’s test, holding the wrists hyper‐flexed (which decreases space in the carpal tunnel.

Question 39

What is non-operative treatment of carpal tunnel syndrome?

Answer 39

Non-operative treatment includes the use of wrist splints at night to prevent flexion. Injection of corticosteroid can also be used.

Question 40

What is surgical treatment of carpal tunnel syndrome?

Answer 40

Carpal tunnel decompression involves division of the transverse carpal ligament under local anaesthetic (one of the most commonly performed surgical procedures). It is usually a highly successful operation, although there is risk of damage to the median nerve or one of it’s smaller branches.

Question 41

What is cubital tunnel syndrome?

Answer 41

Compression of the ulnar nerve at the elbow behind the medial epicondyle (”funny bone” area).

Question 42

What is the presentation of cubital tunnel syndrome?

Answer 42

Patients complain of paraesthesiae in the ulnar 1½ fingers and Tinel’s test over the cubital tunnel is usually positive. Weakness of ulnar nerve innervated muscles may be present including the 1st dorsal interosseous (abduction index finger) and adductor pollicis. The later can be assessed with Froment’s test.

Question 43

What causes cubital tunnel syndrome?

Answer 43

Compression can be due to a tight band of fascia forming the roof of the tunnel (known as Osborne’s fascia) or due to tightness at the intermuscular septum as the nerve passes through or between the two heads at the origin of flexor carpi ulnaris.

Question 44

What is the treatment for cubital tunnel syndrome?

Answer 44

Nerve conduction studies confirm the diagnosis and the patient may need surgical release of any tight structures

Question 45

What is tennis elbow?

Answer 45

lateral epicondylitis
-This can occur as a repetitive strain injury in tennis players and others whom regularly perform resisted extension at the wrist. It can also be a degenerative enthesopathy (inflammation of the origin or insertion of a tendon or ligament into bone).

Question 46

what are the clinical features of tennis elbow?

Answer 46

Clinical features include a painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension.

Question 47

What is the treatment for tennis elbow?

Answer 47

This is a self‐limiting condition (usually resolves). Treatment involves a period of rest from the activities that exacerbate the pain, physiotherapy, NSAIDs, steroid injections and use of a brace (known as an elbow clasp). Ultrasound therapy is also used but its efficacy is unclear.

Rarely, refractory cases may be offered surgical treatment which involves division and/or excision of some fibres of the common extensor origin however has variable results

Question 48

What is golfers elbow?

Answer 48

Medial epicondylitis is a consequence of repeated strain or degeneration of the common flexor origin. Medial epicondylitis is less common than its lateral counterpart.

Question 49

What is the treatment for golfers elbow?

Answer 49

Again this is a self‐limiting condition with physio, rest & NSAIDs the mainstay of treatment. Injection in this area carries a risk of injury to the ulnar nerve.

Question 50

What is dupuytrens contracture?

Answer 50

This is a proliferative connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints.
-50% are bilateral

Question 51

What are the risk factors for dupuytrens contracture?

Answer 51

Males are much more commonly affected (by around 10:1), it can be familial (inherited in an autosomal dominant pattern) and has a high prevalence in those of Northern European / Scandinavian descent. Dupytrens can also be seen as a feature of alcoholic cirrhosis and as a side effect of phenytoin therapy. It is also more common in diabetics.

It can also occur with other fibromatoses including Peyronie’s disease, which affects the penis, and plantar fibromatosis affecting the feet (Ledderhose disease). Young patients and patients with fibromatosis elsewhere tend to have more aggressive forms of the disease.

Question 52

What is the treatment for dupuytrens contracture?

Answer 52

Mild contractures may be tolerated but surgical treatment can be offered if contractures are interfering with function. Up to 30° of contracture can be tolerated at the MCP joint and but the PIPJ readily stiffens and any contracture here is usually an indication for surgery.

Surgery involves either removal of all diseased tissue (fasciectomy) or division of cords (fasciotomy). Recurrence can occur particularly in the younger patient. Severe contractures (finger in palm) may be most appropriately treated with amputation.

Question 53

what is trigger finger?

Answer 53

Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley).

Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley. This sensation may be painful and the finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension. The patient may have to forcibly manipulate the finger to regain extension, usually with pain. Any finger can be affected but the middle and ring are those most commonly affected.

Question 54

What is the treatment for trigger finger?

Answer 54

In most cases injection of steroid around the tendon within the sheath will relieve symptoms. Surgery can be offered in recurrent and persistent cases. Surgery involves incision of the pulley to allow the tendon to move freely. Due to the system of other pulleys, division of the A1 pulley does not affect function.

Question 55

What is a ganglion cyst?

Answer 55

These are common mucinous filled cysts found adjacent to a tendon or synovial joint. They are common in the hand (DIPJ – mucous cyst, flexor tendon) and wrist (dorsal or volar). They can also occur in the foot and ankle as well as the knee (Baker’s cyst).

Question 56

What are the clinical features of a ganglion cyst?

Answer 56

• pain
• irritation
• cysts and firm/smooth/rubbery and transilluminate

Question 57

What is the treatment for a ganglion cyst?

Answer 57

Needle aspiration may be attempted (watch volar ganglion à radial artery) but recurrence is common after this treatment (50‐ 70%).

Surgical excision may be required if the swelling causes localized discomfort. The historic treatment of striking the wrist with a heavy book (“bible technique”) to burst the swelling is not advised.