T&O - Back Pain

Question 1

What is mechanical back pain?

Answer 1

Soft tissue injury, muscle spasm and pain, that may have inciting event (lifting)

Question 2

What is the conservative and medical Mx for mechanical back pain?

Answer 2

• Conservative
  
  • Max 2-day bed rest
  • Physio, warmth
• Medical
  
  • Analgesia: paracetamol + NSAIDS + codeine
  • Muscle relaxant: low dose diazepam for back spasms

Question 3

What is a disc prolapse?

Answer 3

Herniation of nucleus pulposus through annulus fibrosus

Question 4

Describe a typical presentation of disc prolapse

Answer 4

• L5/S1 most commonly compressed by prolapse of L4/L5 and L5/S1 discs
• Severe back pain on sneeze/cough
• Lumbago: lower back pain
• Sciatica: shooting radical air pain down buttock/thigh

Question 5

What type of neuropathy do you get in lateral vs central herniation?

Answer 5

• Lateral herniation = radiculopathy
• Central herniation = cauda equina syndrome (after L1/L2)

Question 6

What symptoms will you get in L4/L5 root compression? Which root is affected?

Answer 6

L5 root compression

• Weak hallucinations extension +/- foot drop
• Decreased sensation in dorsum of foot

Question 7

What symptoms do you get in L5/S1 root compression? Which root is affected?

Answer 7

S1 root compression

• Weak foot plantarflexion and eversion
• Loss of ankle jerk
• Calf pain
• Decreased sensation over sole of foot and back of calf

Question 8

What Ix should you conduct in someone with back pain?

Answer 8

• Vitamin D, FBC, U&E’s, CRP, bone profiles (Ca, albumin, phosphate, ALP), LFT (if bony mets, might have mets there or ALP problems), ESR, LDH (raised in bone marrow cancers),
• Myeloma screen in older pts (Bens-John’s protein in urine, Beta2 microglobulin in blood and serum electrophoresis)
• X-RAY
• MRI (emergency if cauda equina is suspected)

Question 9

What is the conservative, medical and surgical Rx for disc prolapse?

Answer 9

• Conservative: brief rest, mobilisation and physio, analgesia - pt cannot spend many days in bed
• Medical: analgesia/transformational steroid injection
• Surgical: discectomy or laminectomy may be needed in cauda equina/continuing pain/muscle weakness

Question 10

What is spondylolisthesis?

Answer 10

• Displacement of one vertebra on another - usually in fracture of pars intereticularis (usually forward and L5 on S1)
  
  • Occurs in the lower back most of the time

Question 11

What are the causes of spondylolisthesis? Presentation? Dx? Rx?

Answer 11

• Causes
  
  • Congenital malformation
  • Spondylosis (degeneration of intervertebral discs)
  • Osteoarthritis
• Presentation
  
  • onset of pain usually worse on standing, +/- sciatica/hamstring tightness and abnormal gait
• Dx: made with Plain radiography
• Rx: corset, nerve release or spinal fusion

Question 12

What is spinal stenosis?

Answer 12

Definition: developmental predisposition +/- face joint OA leading to generalised narrowing of lumbar spinal canal

Question 13

What is the typical presentation of a pt with spinal stenosis?

Answer 13

Presentation

• Spinal claudication: aching or heave buttock/lower limb pain on walking, rapid onset, may have associated parasthesia/numbness, pain eased by leaning forward
• Pain on spine in extension

Question 14

Spinal stenosis: Ix and Rx

Answer 14

• Ix: MRI
• Rx:
  
  • Corsets
  • NSAIDs
  • Epidural steroid injection
  • Canal decompression

Question 15

Neurosurgical emergencies: acute cord compression - presentation

Answer 15

• Bilateral pain: back and radicular
• LMN signs at compression level
• UMN signs and sensory below compression
• Sphincter disturbance

Question 16

Neurosurgical emergencies: Acute caudal equina compression - presentation and Rx

Answer 16

Presentation:

• Alternative/bilateral radicular pain in legs
• Saddle anaesthesia
• Loss of anal tone
• Bladder +/- incontinence

Rx:

• Cause dependant
• Large prolapse: laminectomy/discectomy
• Tumours: radiotherapy and steroids
• Abscesses: decompression