T&O - Back Pain

Question 1

Radiculopathy

Definition
Aetiology
Clinical Features
Investigations
Symptomatic Management

Answer 1

1. ) Definition - conduction block in the axons of a spinal nerve/roots WITH impact on motor or sensory axons
   - causing weakness or paraesthesia/anaesthesia
   - radicular pain derives from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion
   - myelopathy is compression of the spinal cord itself
2. ) Aetiology - usually nerve compression
   - interveterbral disc prolapse, fracture, malignancy
   - degenerative diseases of the spine e.g. DCM (cervical myelopathy)
   - infection: extradural abscess, osteomyelitis
3. ) Clinical Features
   - sensory (paraesthesia, numbness), motor (weakness)
   - radicular pain is present and can be intermittent
   - radicular pain is burning, deep, strap-like, narrow
4. ) Investigations
   - X-rays: not recommended
   - MRI: red flag sx, sciatica (failed management), neck pain radiating down arm
5. ) Symptomatic Management
   - analgesia, neuropathic medication (e.g. amitriptyline), benzodiazepines (muscle spasms), physio
   - epidural: in acute/severe sciatica

Question 2

Red Flags for Radiculopathy

Cauda Equina Syndrome (CES)
Infection
Fracture
Malignancy

Answer 2

1. ) Cauda Equina Syndrome - low back pain w/:
   - bilateral sciatica, severe muscle weakness
   - perianal numbness, urinary/faecal incontinence
   - erectile dysfunction
   - causes: disc prolapse, bony mets, myeloma, epidural haematoma/abscess, primary sacral tumour
2. ) Infection - discitis (discs) or osteomyelitis (bone)
   - bone pain and systemically unwell (e.g. fever)
   - psoas abscess important differential
   - immunosuppressed, chronic steroid use, IV drug use
3. ) Fracture
   - significant trauma, osteoporosis
   - metabolic bone disease, chronic steroid use
4. ) Malignancy/Metastatic
   - >50, gradual onset, unexplained weight loss
   - severe pain remains when supine, disturbs sleep
   - pain aggravated by straining (e.g. coughing etc.)
   - conservative management ineffective after 4-6wks
   - PH (esp): breast, lung, GI, prostate, renal, thyroid

TUNA FISH
trauma, thoracic pain (cancer)
Unexplained weight loss
Neurological deficit
Age <20 or >50 - cancer 
Fever - infection
Immunosuppression - infection
Spinal tenderness - fracture
History of cancer/infection/TB

Question 3

Degenerative Disc Disease

What is it?
Clinical Features
Investigations
Management

Answer 3

1. ) What is it? - natural deterioration and weakening of intervertebral disc structure, often due to ageing
   - progressive dehydration of the nucleus pulposus
   - daily activities causing tears in annulus fibrosis
2. ) Clinical Features
   - local spinal tenderness, painful back/neck extension
   - contracted paraspinal muscles, hypomobility
   - pain can ↑ intensity and include radiculopathy
3. ) Investigations
   - all need full neuro exam and must rule out CES
   - painful SLR suggests disc herniation
   - imaging only for red flags, radiculopathy >6wks, evidence of spinal cord compression
   - MRI (gold) if imaging is needed (most do not)
   - STaRTBack is a risk stratification tool to aid decision making for lower back pain
4. ) Management - variable and patient dependent
   - NSAIDs + PPI (if >45), first-line for pain management
   - can add paracetamol –> codeine –> tramadol
   - amitriptyline for neuropathic pain relief
   - encourage mobility w/ physio for exercises
   - refer to pain clinic if not better after 3 months

Question 4

Pathophysiology of Degenerative Disc Disease

Dysfunction
Instability
Restabilisation

Answer 4

1. ) Dysfunction
   - outer annular tears, separation of the endplate
   - cartilage destruction, facet synovial reaction
2. ) Instability
   - disc resorption and loss of disc space height
   - facet laxity –> subluxation and spondylolisthesis
3. ) Restabilisation - degenerative changes lead to:
   - osetophyte formation and canal stenosis