Spine problems Flashcards
Disc problems overview
List the pain-producing structures in the back
- nucleus polposus
- annulus fibrosus
- facet joints
- ligaments
- muscles
- nerve (mechanical and chemical irritation)
- synovium (facet joint capsule)
- meninges
Back pain Sx red flags
- FLAWS
- Sx for cauda equina
- Morning stiffness
- Uncontrolled pain
- Thoracic pain
What serious conditions can lead to back pain?
- Cauda Equina
- Pathological fracture
- Cancer
- Infection (TB)
Sx for cauda equina
- Saddle anaesthesia
- Disturbed gait
- Progressive neuro, bladder/bowel/sexual dysfunction
Back pain PMHx/SHx red flags
- <20 or >50
- Hx IVDU
- Hx cancer
- Immunosupression
- TB contacts
Yellow flags back pain- Psychosocial factors for poor prognosis
- Depression, social withdrawal
- Fear avoidance
- reduced activity
- expectation that passive not active treatment will be useful
- social/financial problems
Function vertebrae
- protect cord and nerves
- posture and locomotion
- supports bodyweight above pelvis
- partly rigid axis for head to pivot on
Label the vertebra
Lumbar vertebra
What are the basic steps to spine examination?
1) Obs + inspection inc gait
2) Neurology inc slump or SLR
3) palpate muscles and SP/SIJ
4) assess movement different levels- ROM
5) Special tests
Pharmacological Mx back pain principles
- NSAIDs - ibuprofen/naproxen
- Spasms- short course diazepam
- Codeine + paracetamol (SE advice)
- Sciatic pain- neuropathic meds eg amitriptyline
Impact of smoking on back pain
- strong Ax with LBP and sciatica
- poorer surgical outcomes
Conservative Mx back pain
Exercises and daily activity
• Heat
• + Psychological support (complex protracted cases)
Movement is an essential component of Mx-
- changes pressure distribution in joints/muscles/nerves
- keeps muscles and ligaments strong
Mx neuropathic pain
1) Neuropathic meds:
- amitriptyline, duloxetine, gabapentin, pregabalin
- Tramadol- acute ‘rescue therapy’
- capsaicin cream localised
2) Nerve root blocks
3) Decompression surgery
Causes of cord compressions
- Tumour/lesions (primary/secondary)
- Trauma
- Spinal stenosis (eg by spondylolisthesis- vertebral compression fracture)
- inflam/infection (pagets, TB)
- disc herniation
Where can cord compression occur?
Anywhere- cord, conus medullaris, cauda
C4/5/6- v flexible so most vulnerable
Acute cord compression higher than conus/cauda
Sx of acute cord compression
- UMN SIGNS
- back pain>leg
- signs of infection/cancer
occurs above conus/cauda
Symptoms cauda equina/conus medullaris syndrome
- saddle anaesthaesia/parasthesia
- LBP, unilateral/bilateral radicular pain
- bladder/bowel/sexual dysfunction
Signs cauda equina/conus medullaris syndrome
- perianal/perineal sensory loss
- loss of sphincter tone
- severe/progressive neuro deficit, mostly LMN but can be mixed UMN/LMN
Mx cauda equina
- Imaging ED- MRI goldstandard
- urgent ortho spinal referral for decompression
conus medullaris vs cauda equina syndrome
conus medullaris:
- less common + severe
- bilat + symmetric
- fasciculations
- knee reflex still present
- early, marked bladder/rectal/sexual Sx
- more sudden onset
neurogenic bowel or bladder questions to ask
Can you feel it filling? Urge? Make it in time? Flow problems? Incontinence?
non- spinal lower back pain ddx
Retroperitoneal structures e.g.
- AAA
- renal pyelonephritis/calculus
cancer/infection Sx back pain
- night pain
- systemic Sx
- thoracic Sx
- inc age
- Hx ca
- recent infection eg UTI, surgical procedure
- Fever/septic
- Postural deformity
- point tenderness
- +/- neurology
Sx pathological fracture
- severe pain- rest and night
- RF- osteoporosis, AN, cancer
- sport- rowing, synchronised swimmer (pars/sacral resp)
Need high index of suspicion
Mx pathological fracture
- analgesia
- surgery - unstable, deformity, Rx pain
- vertebroplasty/fusion
Inflammatory back pain Sx
- morning stiffness
- Insidious onset then chronic
- young, female
- Hx/FHx AI disease
- sacroilitis common initial pres
Signs inflammatory back pain
- Pain on SIJ palpation
- FABER test- leg flexed, abducted and externally rotated
Ix inflam back pain
- bloods- CCP, RF, ANA
- MRI/xray
Where does mechanical back pain most commonly occur?
- lumbar
- may or may not involve nerve root
- diskogenic/facet joint pain
Symptoms acute spinal cord compression/discogenic back pain
- unilateral, leg pain radiating below knee (L5)
- leg Sx > back Sx
- parasthesia, weakness
- cough/sneeze/heavy lift inc. pain
- worse on FLEXION
Clinical features acute spinal cord compression/diskogenic back pain
- loss of reflexes in nerve root distribution
- list to contralateral side from pain
- straight leg raise <30 deg, positive slump test
- acute muscle spasm on palpation
Mx acute spinal cord compression/diskogenic back pain
- analgesia
- weak opiod short course
- Benzo
- physio
- surgical decompression
Facet joint pain is usually caused by what condition
degenerative arthropathy
Sx facet joint pain
- chronic
- older
- aggravated by EXTENSION and LATERAL FLEXION
- +/- nerve root Sx
- decreased ROM
- tender on palpation
Ix facet joint pain
- MRI gold standard
- CT
- Bone
Mx facet joint pain
- as for arthritis and chronic LBP
- facet joint injection (diagnostic and therapeutic)
Types of spondylolisthesis/spondylolysis
Type 1: dysplastic/congenital
Type 2: pars defect (lytic i.e. stress fracture, acute fracture)
Type 3: degenerative
Type 4: traumatic
Type 5: pathological 2/2 bone disease eg osteogenesis imperfecta, pagets
Who is affected by stress fracture of pars interarticularis?
- Young athletes
- hyperextension + rotation
- fast bowlers, gymnasts
Sx stress fracture of pars interarticularis
Unilateral LBP
- pain aggravated with extension
- may have single episode precipitated pain
- may be aSx if stress
- excessive lumbar lordosis + HS tightening
- unilat tenderness on palpation
Ix for stress fracture pars interarticularis
- oblique- scotty dog
- SPECT bone scan
- MRI less sensitive
Most common site for spondylolisthesis
L4/5
What is spondylolithesis and what is required for it to occur?
Slipped vertebra
requires bilateral pars defect
Sx spondylolisthesis
- LBP +/- leg pain
- +/- claudication if central stenosis
- palpable dip
- compensatory muscle spasms in HS
- decreased ROM
- lordosis
Ix for spondylolisthesis
Lateral XR- grade slippage
Mx spondylolithesis
- relative rest
- analgesia
- PT
- avoid contact sport
- if progresses (rare)- surgery
signs and symptoms lumbar spinal stenosis
- elderly (affects 11% population)
- LBP
- Parasthesia and pain on prolonged standing/walking
- neuro exam- plantars and Hoffmans, Romberg
Most common primary malignancies that metastasise to the spine
thyroid, lung, breast, renal, and prostate
haematological malignancies eg myeloma
Lumbar spinal stenosis causes
- ligamentum flavum hypertrophy
- facet degeneration- osteophyte formation
- disc herniation
Mx lumbar spinal stenosis
Conservative = analgesia, exercises to improve spine mobilisation. Degenerative condition- aim to stabilise rather than cure
If severe and Rx to conservative Mx - surgical decompression =/- fusion
Torticollis
‘cricked neck’
pain and difficulty turning head C4-7
Can be apophyseal or diskogenic
Burners and stingers
traction injury to brachial plexus
contact sport
burning/stinging sensation down arm
scheuermann’s disease
excessive thoracic kyphosis, most commonly adolescent males
causes of thoracic back pain
- scheuermann’s disease
- costovertebral and costotransverse joint disorders (inflam arthritidies or mechanical)
- other: chest, cardiac, oesophagus
if no neuro red flags Mx back pain
- tell to move
- reassure
- analgesia with NSAIDs
- PT
- no imaging
criteria for learning disability paralympics
IQ below 70-75
Intellectual disability must have been observed in developmental period (0-18 yrs.)
Must be receiving 2 out of
- Special education
- Special accommodation
- Special employment
- Special protection
- Respite care
- Financial support
Lesion above T6 max HR
Cannot go above 120-130 because no sympathetic drive to the heart
