Spine: PIVD and backache Flashcards
What is important to understand about history of backache
Usually insidious onset
Exact date suggests different cause
Beware
What are the Red Flags of back pain?
Non mechanical
Systemic upset
Major, new, neuro deficit
Saddle anaesthesia +/- bladder/bowel upset
What is non mechanical pain?
Doesn’t vary with activity of time of day
Pain worse at night
What is involved in examination of the back?
observation range of movements neuro assessment nerve root irritation distraction testing
How do you observe the back?
Posteriorly
Laterally
With forward flexion to accentuate deformity
How do you assess range of movement?
Schober’s test forward flexion
Qualtative extention
Lateral flexion
what is involved with a neurological assessment of the back?
myotomes
dermatomes
reflexes
nerve irritation
What myotomes are involved in
a) hip flexion
b) knee extention
c) foot dorsiflexion and Extensor Hallicus Longus
d) ankle plantarflexion?
a) L1/L2 (push up against your hand)
b) L3/L4 (straighten knee against your hand)
c) L5 (extend against your hand)
d) S1/S2 (stand on tip toes)
What are additional signs to look for when assessing pain?
pain drawing behavioural symptoms behavioural signs overt pain behaviour walking aids
What are examples of overt pain behaviour?
guarding bracing rubbing grimacing sighing
How can you assess a patient who can’t flex their hip to the desired 90 degrees?
Get them to sit up
will now unknowingly be at 90 degrees
Why should you beware of x rays in back pain?
will show up age related degeneration
What investigations can be used for back pain?
Xray (beware) MRI (beware) Facet injection Contrast CT Provocation discography Nerve block/ablation
What is sciatica?
buttock and or leg pain
specific dermatomal distribution
accompanied neuro disturbances
How does disc prolapse relate to sciatica?
Causes leg pain and neurology
Surgery of disc to treat leg pain
effect on back pain uncertain
How do prolapsed discs present?
Episodic back pain
onset leg pain +/-neurology
Leg pain becomes dominating complaint
myotomes and dermatomal dirstribution
How is disc prolapse treated?
Not emergency Beware of cauda equina (is an emergency) most will settle in 3 months even more settle in 24 months Surgery -only consider if not resolved in 3 months (risky, only speeds up natural process)
How can you manage backache?
1st: Short bed rest (debatable) anti inflammatory +/- muscle relaxant exercise 2nd: physiotherapy chiropractic pain clinic complementary therapy Surgery
What treatments are discredited in back ache?
bed rest bed rest and traction narcotics >2weeks benzodiazapine >2 weeks steroids plaster jacket manipulation under GA
What is the major risk of back surgery?
Adjacent segment disease
after fusion of facets
multi level disease
What are the adverse factors of spinal surgery?
Litigation
Dispute with DSS
Chronic pain syndrome
What contributes to chronic pain syndrome?
central pain perception dorsal horn (NMDA receptors) Mid brain anterior cingulate region cord changes pain and psychosocial
What are the dysfunctional syndromes?
Back pain Chronic fatigue Fibromyalgia IBS Migrane Chronic pelvic pain
What are behavioural symptoms of pain?
Pain at tip of coccyx whole leg pain whole leg numbness whole leg giving way absence of pain free spells intolerant of treatment emergency admission
