The Lumbar Spine and Neck Flashcards
What are the red flags of back pain?
Age under 20 or over 60 Thoracic pain Previous carcinoma Immunocompromise Feeling unwell Weight loss Neuro symptoms Structural spinal deformity Bilateral leg pain Pain at night
What are the yellow flags?
Low mood High pain levelds Belief that activity is harmful Low educational level Obesity Problem with claim?compensation Job dissatisfaction Light duties not available at work Lifting at work
What are potential causes of mechanical back pain?
Obesity Poor posture poor lifting technique Lack of physical activity Depression Degenerative disc prolapse Facet OA or Sponylosis
What is spondylosis
When intervertebral discs lose water content with age resulting in less cushioninf and increases pressure on facet joints leading to secondary OA
When does an acute disc tear classically occur
after lifting a heavy object
What is characteristic of discogenic pain
worse on coughing
What is sciatica
If a disc tear occurs the nucleus pulposis may herniat and press on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution and a loss of power in a myotomal distribution
Where is the most common site for discs to impinge on nerve roots
L4, L5 and S1 - the nerve roots of the sciatic nerve- hence the name sciatica
What is the pain like in sciatica
Neuralgic burning or tingling pain radiating down the bacl of the thigh below the knee (note back pain may radiate down legs but not below the knee)
What nerve root will be entrapped by a L3/L4 disc prolapse
L4 - usually the nerve root below unless very lateral prolapse
What are the signs of an L4 root entrapment
Pain down to MEDIAL ANKLE
Loss of quadriceps power
Reduced knee jerk
What are the signs of an L5 root entrapment
Pain down to DORSUM of foot
Reduced power Extensor hallicus longus and tibialis anterior
What are the signs of S1 entrapment
Pain to SOLE of foot
Reduces power plantarflexion
Reduced ankle jerks
What is spinal stenosis
Varies pathologies causes the lumbar spinal canal to reduce in size leaving less room for the cauda equine and resulting in multiple nerve roots being compressed
What can cause spinal stenosis
Sponylosis
Bulging discs
Bulging ligamentum flavum
Osteophytes
What is the characterisitcs of spinal stenosi
Claudication (pain in legs on walking)
Burning pain not cramping
Pain is less when walking uphill
typically aged over 60
What is cauda equine syndrome?
A very large central prolapse disc can compress all the nerve roots of the cauda equina resulting in a specific clinical syndrome
Why is cauda equina syndrome a surgical emergency
affected nerve roots include the sacral nerve (s4 and s5) roots controlling defication and urination - can result in permanent nerve damage if untreated and patient may require colostomy and urinary diversion
What are the symptoms of cauda equina?
Bilateral leg pain
Parasthesisa or numbness of the saddle region and perineum
Faecal incontinence and constipation
Urinary retention or incontinence
What are the classic symptoms of cervical spondylosis
Slow onset stiffness and pain in neck
Radiate to shoulders and occiput
What do patients complain of is they have a nerve root compression in the cervical spine
Shooting pain down a dermatomal distribution with weakness and loss of reflexes
Which nerve root is typically affected in a cercial disc prolaspe
the lower nerve root ie C6/7 will impinge nerve root C7
In which conditions can atraumatic spine instability occur
Down syndrome
Rheumatoid arthritis
what is characteristic of disc pain
worse on coughing
treatment of an acute disc tear
analgesia and physio
takes about 2-3 months to settle
outline the treatment options of sciatica
1st line is analgesia, mobilise (but no heavy lifting) ad physio
gabapentin can be used in leg pain very severe
usually recover spontaneously in around 3 months
occasionally need surgery - discectomy
what are the indications for surgery in sciatica
pain not resolving with conservative management + localising signs suggesting a specific nerve root + positive MRI corresponding with this
contraindications to discetomy include - evidence of secondary gain or psychological dysfunction
what are the key examinations to perfomr in sciatica type pain
straight leg raise - pain in leg
bragers test - dorsiflexion in straight leg raise increases pain
also do full lower limb neuro spine and hip exam
describe the difference between spinal stenosis symptoms and peripheral vascular disease
in spinal stenosis:
- claudication in inconsistent
- pain is burning
- in in less walking up hill
- pulses are preserved
how is spinal stenosis managed
initially conservatively with physio weight loss and analgesia
if fails to respond or there is MRI evidence of stenosis, surgical decompression may be performed
how should you manage a patient presenting with symptoms of cauda equine
must perform PR examination
urgent MRI scan
urgent referral to neurosurgery for discetomy
who is at risk of atraumatic cervical spine instability (and therefore atlanto-axial instability/subluxation)
rheumatoid arthritis
Down’s syndrome
be careful if getting a GA as airway manoeuvres may precipitate
screen with flexion extension x rays
