Spine and Upper Limb (Dundee bones) Flashcards
Mechanical back pain
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.
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.
What is 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.
Treatment for mechanical pain
Analgesia and physiotherapy
Is bed rest advised in mechanical pain?
Bed rest is not advised as this will lead to stiffness and spasm of the back which may exacerbated disability.
What is instability? (back)
excessive motion caused by a degenerate disc
Acute disc tear (discogenic back pain)
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.
When is disc tear pain worse?
Coughing
When might you tear a disc?
Typically on lifting a heavy object, e.g. lawnmower
Pain is severe
How long does it take a disc tear to heal?
2-3 months
Sciatica symptoms
The radicular pain is felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee. (Note back pain can radiate to the buttock and thigh but not below the knee)
Constant pain in only one side of the buttock or leg (rarely can occur in both legs)
Pain that is worse when sitting
Burning or tingling down the leg (vs. a dull ache)
Weakness, numbness or difficulty moving the leg or foot
A sharp pain that may make it difficult to stand up or to walk
Test used to assist diagnosis of sciatica
perform sciatic stretch test - dorsiflex foot at this point of discomfort - test is positive if additional pain results
L3/L4 entrapment
L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
L4/L5 entrapment
L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
L5/S1 entrapment
L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks
Bony nerve root entrapment
OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica.
Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates.
Why is spondylosis different to PVD (peripheral vascular disease?)
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
Which nerves are compressed in cauda equina syndrome?
Mainly S4 and S5
Spine and upper limb red flags
- Cauda equina syndrome
- Back pain in the younger patient (60 years)
Back pain in the older patient may represent arthritic change or a crush fracture. However patients in this age group are at higher risk of neoplasia, particularly metastatic disease and multiple myeloma.
- Nature of pain ‐ constant, severe pain, worse at night
Mechanical back pain is worse with activity and tends to be relieved by rest. Pain from tumour or infection tends to be constant, unremitting, severe and worse at night.
- Systemic upset
Fevers, night sweats, weight loss, fatigue and malaise may indicate the presence of underlying tumour or infection.
Any suspicion of underlying infection or tumour requires thorough history and examination with potential investigations including bloods (CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA for males, blood culture if suspecting infection), spine xray (may show vertebral collapse of loss of a pedicle on AP view), chest xray, bone scan and MRI scan.
Symptoms of cauda equina syndrome
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.
In essence, any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise.
Cauda equina syndrome
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.
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.
In essence, any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise.
A rectal examination (PR) is mandatory and it is considered negligent not to perform this is a cauda equine syndrome is missed.
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.
Which examination is mandatory in possible cauda equina syndrome?
Rectal examintation
What do you do if you suspect cauda equina syndrome?
-Rectal examination (OR ELSE)
-Urgent MRI (detect level of prolapse)
-Urgent discectomy once diagnosis is confirmed
(rectal exam->MRI->surgery)
What should you consider diskitis with?
Emedicine says you should consider diskitis with osteomyelitis because they often occur together
Diskitis presenting complaint
Neck or back pain with localized tenderness is the initial presenting complaint. Movement exacerbates these symptoms, which are not alleviated with conservative treatment (eg, analgesics, bed rest).
Osteoma vs osteosarcoma, which one would you rather have?
Osteoma is benign
Osteosarcoma is malignant
What could new back pain in the older patient (>60) suggest?
Back pain in the older patient may represent arthritic change or a crush fracture. However patients in this age group are at higher risk of neoplasia, particularly metastatic disease and multiple myeloma.
What could back pain in the young patient be? (<20)
Significant back pain in childhood, adolescence or early adulthood is uncommon. Younger children are more susceptible to infections (osteomyelitis, discitis) whilst adolescents are the peak age for spondylolisthesis as well as some benign (eg osteoid osteoma) and malignant (eg osteosarcoma) primary bone tumours. Clinicians should have a low index of suspicion for referral or MRI.
Difference between mechanical back pain and pain from infection/tumour?
Mechanical back pain is worse with activity and tends to be relieved by rest. Pain from tumour or infection tends to be constant, unremitting, severe and worse at night.
Which tests should you carry out if suspicious of an infection? (general)
Any suspicion of underlying infection or tumour requires thorough history and examination with potential investigations including bloods (CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA for males, blood culture if suspecting infection), spine xray (may show vertebral collapse of loss of a pedicle on AP view), chest xray, bone scan and MRI scan.
Which condition could a balloon vertebroplasty be used? (Only if you have decided to try something different to conservative treatment)
Osteoporotic crush fracture
Cervical Spondlyosis
As with the rest of the spine, spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints. 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.
Osteophytes can also impinge on the exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes which may require decompression for severe symptoms resistant to conservative management.
Cervical disc prolapse
Acute and degenerative disc prolapse can also occur in the cervical spine producing neck pain and potentially nerve root compression.
With nerve root compression, patients complain of shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected. Typically, the lower nerve root is involved (ie C7 root for C6/7 disc, C8 root for C7/T1 disc). A large central prolapse can compress the cord leading to a myelopathy with upper motor neurone symptoms and signs.
Clinical findings and MRI will aid diagnosis of the affected level and again for cases resistant to conservative management, surgery may be considered (discectomy). As with lumbar disc prolapse, the number of patients with asymptomatic disc prolapse increases with age resulting in a higher rate of “false positives” or “incidental findings” on MRI scanning. Clinical findings should correlate with MRI findings before contemplating surgery.
Cervical spine instability and Down syndome
Children with Down syndrome are at risk of developing atlanto‐axial (C1/C2) instability with subluxation potentially causing spinal cord compression. Screening with flexion‐extension xrays will demonstrate the abnormal motion (high atlanto‐dens interval). Children with minor degrees of instability may be prevented from high impact / contact sports. Severe instability or the presence of abnormal neurology may require surgical stabilization.
