Spine & Back Pain Flashcards by Kieran Ruthven

Mechanical pain varies according to activity and time of day, true or false?

False

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Back pain should be worse at night. True/false?

False

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Schober’s Method tests what?

Range of spinal flexion (10cm above, 5cm below)

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What cm is normal movement in Schober’s Method?

21cm

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Which cm is stiff in Schober’s Method?

<18cm

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Which cm is hypermobile in Schober’s Method?

> 24cm

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Hip flexion (straight leg raise) tests which nerve root vertebra?

L1/L2

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Knee extension tests the nerve roots at which vertebral levels?

L3/L4

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Dorsiflexion of the foot tests the nerve roots at which vertebral level?

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X-rays are useful in back pain investigations. True/false?

False - 99% of back pain will give no abnormality on x-ray

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Disc prolapse is always painful. True/false?

False

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Common presenting symptoms of disc pain include (3)

1) Episodic back pain
2) Leg pain becoming dominant in life
3) Specific myotome/dermatomal involvement

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Which % of patients with disc pain will settle within 3 months?

70%

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Surgery is clearly better than other management options in disc prolapse. True/false?

False - no clear benefit versus conservative (90% will resolve within 18-24 months)

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Surgery should be considered if back pain does not resolve after how long?

> 3 months

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First line therapy in back pain outline (4)

1) Short bed rest (NOT prolonged)
2) NSAIDs (with a SHORT course of muscle relaxants, i.e. a day or two)
3) Mobilisation ASAP
4) Return to normal activity ASAP

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Second line therapy for backache (4)

1) Education
2) Physiotherapy
3) Osteopathy / osteopath
4) TENS / pain clinic

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Red flags in back pain include (5)

1) Non-mechanical (i.e. constant)
2) History of cancer
3) Age <20 years or >60 years with first back pain
4) Saddle anaesthesia
5) Longer than 6 weeks of pain

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Central cord injuries classical result from what type of injury?

Hyperextension

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Brown-Sequard Syndrome presents how

Paralysis on the ipsilateral side and paesthesia on the contralateral side. Best prognosis spinal injury.

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AS should immediately be immobilised in a collar and x-rayed. True/false?

False - immobilise in natural position and refer for CT immediately

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Describe the normal spinal curves (3)

1) Cervical lordosis
2) Thoracic kyphosis
3) Lumbar lordosis

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Which structure on the spinal column connects to the spinal body?

Pedicle

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C1 has no vertebral body. True/false?

True - instead it has arches

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What makes C2 unique?

Has a dens which projects into C1

Spinal ligaments can only be directly visualised how?

MRI

Spinal cord is shown on X-ray. True or false?

False

Spinal cord is shown on CT. True/false?

True - although poor. Optimal modality is MRI

What is the normal number of vertebra? How are they divided?

``` 33 7 Cervical 12 Thoracic 5 Lumbar 5 Sacral (fused) 4 Coccyx (fused) ```

The intervertebral discs are what kind of joint

Secondary fibrocartilaghinous

Articular joints of the spine are which type of joint

Synovial

Articular joints of the spine enable which movements (3)

1) Extension 2) Flexion 3) Lateral Flexion

Which area of the spine has the greatest ROM?

C-spine

Which area of the spine has the LEAST degree of extension/ flexion?

Thoracic

Spondyolysis causing secondary OA of the spine will be exacerbated with which movement

Extension (moves more pressure onto facet joints)

An MRI is diagnositic for disc degeneration, T/F?

False - 60% of people over 45 will have asymptomatic bulging spines

What are the commonest areas for disc prolapse?

L4/L5 | L5/S1

What is the underlying pathophysiology in an acute disc tear?

The annulus fibrosus is torn, allowing the inner nucleus pulposus to leak out

Acute disc tear pain will be worsened by which movement

Cough (raises pressure)

From the spine, motor/ efferent neurones exit from the anterior or posterior horn?

From the spine, sensory / afferent neurones exit from anterior or posterior horn?

Posterior

From the spine, nerves exit through which osteological structure?

Intervertebral foraminae

The spinal cord ends at which level

L1-L2

The exiting nerve root from a spine exits at which level?

Under pedicle of same level (i.e. L4 at L4)

A transverse nerve root of the spine exits at which level?

Under pedicle of the level below (i.e. L5/S1 exits at S1)

What are the nerves contained within the spine?

Thecal sac

Most disc prolapses affect the exiting or transverse nerve root?

Transverse (i.e. level below)

A very lateral prolapse can affect which nerve root?

Exiting root

What is a radiculopathy

Pain and weakness down a specific dermatome with associated loss of power in the corresponding myotome & loss of appropriate reflexes

How can mechanical back pain be confused for sciatica?

Mechanical back pain can radiate to the buttocks & thigh. Sciatica however must present below the knee.

The nerve roots of which level are affected in sciatica?

L1, L2, and L3.

Spinal stenosis is root compression due to...

Osteophyte formation (e.g. in OA) or hypertrophic ligaments (especially ligamentum flavum)

Radiculopathy pain will be worse/ better upon walking?

Worse (neurogenic claudication)

Patients with radiculopathy pain will find it easier to walk up or downhill?

Uphill (encourages natural flexion)

Cauda Equina is caused by compression where?

On ALL lumbosacral roots

What's the usual cause of Cauda Equina?

Disc prolapse

What are the muscles of the spine? Why are these important to know?

Iliocostalis, longissumus thoracis, spinalis thoracis (collectively the "erector spinae"). Important as these can be a source of sprains/strains.

What is a Chance fracture? What is a frequent cause?

Fracture of the vertebral body. Often due to seatbelt injury. Very unstable.

What vertebral level are LPs performed at?

What are the overt pain behaviours?

Guarding, bracing, rubbing, grimacing, sighing.

X-rays are useful in diagnosis of back pain, T/F?

False - 99% will have no unexpected abnormality

First-line investigation for back pain in a clinic

MRI

What older imaging technique is useful for showing spinal stenosis?

Myelogram

What is sciatica?

Buttock and/or leg pain in a specific dermatome with myotomal weakness and loss of reflexes (neurological involvement)

Slipped discs are always symptomatic, T/F?

False

What are common presentations of slipped disc?

Episodic pain in back/ leg with or without CNS involvement. Pain in leg becomes dominant over back pain.

Is disc prolapse a surgical emergency?

Not unless cauda equina is present

What % of disc prolapse will resolve within 18-24 months?

90%

T/F: surgery has been shown to have long-term benefits for treatment of slipped disc versus conservative treatment?

False - the benefit is short term as outcomes at 2, 5 and 10 years are the same for surgical and conservatively managed patients

How is back-pain treated (conservative)? (4)

Short bed rest (as little as possible without pain), NSAIDs +/- a day or two of muscle relaxant, early mobilisation and early return to work

What treatment options have been discredited in management of slipped disc?

Longterm bed rest, narcotics >2 weeks, muscle relaxant >2 weeks, steroids.

Describe the 2nd line treatment options for back pain

Education, physiotherapy, TENS & complimentary therapies

What is a risk of surgery for back pain?

Chronic pain syndrome, adjacent segment disease

What % surgeries for back pain are successful?

75-80%

What % of surgeries for back pain fail?

Up to 25%

What % of surgeries for back pain result in CNS damage?

0.5-1%

What % of surgeries for back pain result in worse outcomes than what was present pre-surgery?

3-5%

When does adjacent segment disease present after a level 2 spine fusion?

8-10 years

When does adjacent segment disease present after a level 3 spine fusion?

18-24 months

When does Cauda Equina need to be treated?

Within 24 hours

Cauda Equina causes which kind of urinary symptom? Is it painful?

Painless retention with urinary overflow

Do most Cauda Equina cases present with the same general symptoms?

No, most are atypical and have unusual presentation (e.g. no pathology present on imaging but symptoms present)

Cauda Equina symptoms usually progress to Cauda Equina Syndrome, T/F?

False - most do not have any serious issue.

In a suspected spine injury, what are the first 3 management tasks?

1) Immobilise 2) ABCDE 3) X-ray

Assessment of spinal injuries involves which 3 processes?

1) X-ray (if C-spine injury suspected this MUST show C7 and T1) 2) Neurological exam (especially of the saddle area) 3) Screen for spinal cord involvement (note may not appear on X-ray, and spine cord can become involved in secondary damage e.g. due to hypoxia or oedema)

Which level of the spine do thoracolumbar injuries tend to present at?

T12 or L1

Which area of the spine should be visulised if suspected thoraco-lumbar injury?

Entire spine

What are the characteristics of a complete spinal cord injury?

1) Saddle sparing (ANY saddle involvement means not complete) 2) Progressive weakness/numbness 3) Ascending lesion (eventually giving a "cape anaesthesia")

Central Cord Injury is complete/incomplete. It typically results from ____ type of injury. The prognosis is....

Incomplete Hyperextension Prognosis variable but generally good

Brown-Sequard injury is complete/incomplete. Typical symptoms include (2). The prognosis is...

Incomplete. Paralysis on ipsilateral side and loss of pain sensation on contralateral side. Best prognosis of spine cord injuries.

Anterior cord injury is complete/incomplete. Symptoms include (2). Prognosis is generally...

Incomplete. Symptoms are: loss of pain and temperature sense BUT preserved deep touch, position and vibration. Prognosis is very poor.

Anterior cord injury can result from which injury type

Trauma or vascular injury (e.g. a complication of repair of AAA)

When should spinal cord surgery be commenced?

Within 7-10 days (allows swelling to settle down).

Is it always a good idea to surgically stabilise the spine immediately after spine cord injury detected?

No - the area begins to swell.

Chance fracture is stable/unstable.

Unstable - requires surgery.

What's the key difference in managing spinal injury in patients with AS versus spinal injury in otherwise healthy patients?

Do NOT use collars etc. in AS as this creates a lordosis at the collar which worsens damage angle.

In a suspected C-spine injury in patients with AS, what investigation must be done?

MRI should be performed in which cases? (2)

1) If red flags present | 2) If considering surgery (e.g. for spinal stenosis)