Spine Trauma - Discitis, Lower back pain, Prolapsed disc, Lumbar spinal stenosis, Epidural abscess, Iliopsoas abscess

Question 1

Discitis
-pathophysiology
-causative organisms
-presentation
-investigations

Answer 1

Infection in intervertebral disc space => potential to lead to sepsis/epidural abscess

MOST COMMON - Staph aureus
Viral, TB, aseptic

Back pain
Fever, rigors, sepsis
Neurological features

MRI - confirm
CT guided biopsy - guide antimicrobial treatment
Endocarditis assessment - discitis came from somewhere

6-8wks IV ABx

Question 2

Lower back pain (non specific)
-risk factors for non specific back pain
-presentation
-red flag conditions to be aware of
-investigations
-management

Answer 2

Past Hx
Obesity
Physical inactivity
Physically demanding occupations
Chronic health conditions
Lower SES, smoking

Lumbosacral, exacerbated by movement
Varies with time and posure

RED FLAGS
CES
-bilateral sciatica
-bowel/bladder changes
-sadddle anaesthesia
-lower limb neuro deficit

Spinal fracture
-sudden onset severe spinal pain improved when lying down
-TRAUMA
-point tenderness

Cancer
-gradual progressive pain
-night spinal pain affecting sleep
-waking up in the night from pain
-worsened on movement, sitting, standing
-no symptomatic improvement after 6wks conservative
-B symptoms
-cancer Hx

Infection - discitis, osteomyelitis, epidural abscess
-fever, systemically unwell or recent infection
-DM, IVDU, HIV, IC

If non specific suspected - no imaging
MRI - if management likely to change/red flag conditions?

Exercise programme
NSAIDS

Question 3

Prolapsed disc
Presentation
-L3
-L4
-L5
-S1

Answer 3

Leg pain worse than back
Worse when sitting

L3
-ant thigh sensory loss
-weak hip flex, knee ext
-reduced knee reflex
-pain on femoral stretch test

L4
-ant knee, MM sensory loss
-weak knee ext
-reduced knee reflex
-pain on femoral stretch test

L5
-dorsum sensory loss
-weak foot, big toe dorsiflexion
-reflexes ok
-positive SLT

S1
-posterolateral leg, LM sensory loss
-weak plantarflexion
-reduced ankle reflec
-positive SLT

Question 4

Prolapsed disc
-management

Answer 4

Analgesia - NSAID+PPI
-if symptoms persist after 4-6wks => refer for MRI
Physio

Question 5

Lumbar spinal stenosis
-pathophysiology
-presentation
-investigations
-management

Answer 5

Spinal canal narrowed by tumour, disc prolapse or degenerative changes

Back pain
Neuropathic pain
Claudication symptoms
Pain better when
-sitting
-walking uphill

MRI

Laminectomy - bony part of spine removed

Question 6

Sciatica
-presentation
-spinal roots affected
-investigations
-management

Answer 6

L4-S3

Unilateral leg pain radiating to feet
Dermatomal/myotomal changes
Positive SLT

Self limiting - few weeks-months
Encourage normal activities - work adjustments
-prolonged bed rest NOT recommended
Local heat
NSAIDS

Question 7

Back pain red flags

Answer 7

Cauda equina
Acute spinal cord compression
Tumour/infection

Question 8

Epidural abscess
-what is it
-common causes and risk factors
-presentation
-investigations
-management

Answer 8

Abscess above dura mater- NEEDS URGENT TREATMENT TO ACOID SPINAL CORD DAMAGE

STAPH AUREUS
Contiguous spread - discitis
Hematogenous spread - ICUD
Direct infection - spinal surgery
-IC, HIV, DM, ETOH, chemo, CS

Fever back pain
Focal neurological deficits relating to segment of cord affected

Bloods - CRP, HIV, HepB,C, preop bloods (coag and G&S), cultures
Infection screen CXR, Urine MSC
MRI whole spine - skip lesions

Long term ABx
If not responding or have neuro deficits => surgical evacuation

Question 9

Iliopsoas abscess
-what is it
-common causes and risk factors
-presentation
-investigations
-management

Answer 9

Pus in iliopsoas compartment - iliopsoas and iliacus
-hematogenous spread (staph aureus)
-Crohns
-IVDU
-UTI, GU cancers

Fever
Back/flank pain
Limp, difficulty extending affected hip
Weight loss

Patient supine with knee flexed and hip slightly externally rotated
Pain elicited hip hyperextended hip
Pain elicited when patient asked to lift thigh up against hand

CT abdo

1st line - ABx and percutaneous drainage
Surgery if drainage unsuccessful or another intraabdominal pathology needing surgery

Question 10

Neoplastic spinal cord compression
-common causes
-presentation
-investigations
-management

Answer 10

Lung, breast, prostate cancer

Back pain - worse of lying down and coughing
Lower limb weakness
Sensory loss/numbness
Above L1 - LL UMN and sensory level
Below L1 - LL LMN and perianal numbness

Urgent MRI whole spine within 24hrs

High dose PO dex
Urgent assessment for RT or surgery