The Problems are back

Question 1

What are the 3 types of back pain?

Answer 1

Mechanical
Systemic
Referred

Question 2

What is mechanical back pain?

Answer 2

Most common cause of back pain

Pain elicited with spinal motion and decreases with rest

Question 3

What are the potential causes of mechanical back pain?

Answer 3

Lumbar strain/sprain - disruption of muscles or stretching of ligaments
Degenerative disc and/or facets - increases with flexion, sitting and coughing/sneezing due to an increase in intradiscal pressures
Herniated nucleus pulposus - referred pain from a corresponding tear in annulus fibrosis
Spondylolysis - aggravated by extension
Compression fracture - secondary to osteoporosis
Sacroiliitis - degenerative

Question 4

What is the management for mechanical back pain?

Answer 4

Bed rest
Physical activity
Ice and heat application
Muscle relaxants
Physical therapy

Question 5

What is referred back pain?

Answer 5

Typically non-spine related and include intra/retroperitoneal pathologies; 2% prevalence

Question 6

What might cause referred back pain?

Answer 6

Aortic aneurysm
Acute pancreatitis
Acute pyelonephritis
Renal colic
Peptic ulcer disease

Question 7

How would you manage referred back pain?

Answer 7

A short period of rest e.g. 1-2 days
Physical therapy, active exercises and stretching
Ice packs and/or hot pads
Appropriate medications for pain relief

Treat underlying condition

Question 8

What can cause systemic back pain?

Answer 8

Infection: Untreated discitis, osteomyelitis, or epidural abscess can lead to sepsis, preogresive kyphotic deformity and/or neuro deficit
Inflammatory spondyloarthropathy e.g. ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis
Connective tissue disorder

Question 9

How would you manage systemic back pain?

Answer 9

Warrant further work up

Possible urgent referral to spine surgeon

Question 10

What are the major features of back pain assessment?

Answer 10

Look for red flags
Patient gait and ability to walk should be observed
Palpate spine to localise tenderness 
Test range of spinal motion
Neurological examination
Rectal tone
General physical examination

Question 11

What are the red flags for back pain?

Answer 11

Systemic ailments including fever, chills, night sweats and/or unexplained weight loss (infection/malignancy)
History of malignancy or IV drug use
Profound or progressive neurological deficit
Sphincter disturbance (bladder or bowels)
Trauma/high speed injury
Pain refractory to medicine/injections; thoracic pain; non-mechanical pain or pain at night
Age <20 or >50 yrs
Prolonged corticosteroid drugs or other immunosuppressive therapies
Presence of contusion or abrasions over the spine

Question 12

When should back pain patients be referred?

Answer 12

Back pain associated with infection or tumour
Patients on immunosuppresive therapy or with history of IV drug use
CT/MRI in those with unrelenting pain despite treatment or with systemic ailments
Trauma, esp minor trauma in older pts and those with OP

Question 13

When should X-rays be used?

Answer 13

Most with low back pain with or without sciatica do not routinely require imaging in non-specialist setting.
No red flags or high risk features mean they should be reassured their symptoms will respond to conservative treatment.
If symptoms persist longer than 6-8 weeks, plain X-rays should be taken as benign low back pain aetiology should have improved.

Question 14

What are the non-pharmacological treatments for back pain?

Answer 14

Self-management
Exercise - choose specific type depending on pain
Spinal manipulation, mobilisation or soft tissue techniques such as massage
Psychological therapy
Combined physical and psychological programmes

Question 15

What non-pharmacological treatments are NOT recommended for back pain?

Answer 15

Orthotics – do not offer belts or corsets, foot orthotics or rocker sole shoes
Acupuncture
Ultrasound, percutaneous electrical nerve stimulation or interferential therapy

Question 16

What are the pharmacological treatments for back pain?

Answer 16

NSAIDs

Weak opioids with or without paracetamol

Question 17

What pharmacological treatments are NOT recommended for back pain?

Answer 17

Paracetamol alone 
Opioids for management
Opioids for chronic back pain
SSRIs, serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants for management
Anticonvulsants

Question 18

What is Cauda Equina Syndrome?

Answer 18

Condition affecting the bundle of nerve roots and nerves (cauda equina) at the lumbar end of the spinal cord.
Occurs when the nerve roots in the lumbar spine are compressed, cutting off sensation and movement.
Nerves of the cauda equina provide motor and sensory function to the legs and the bladder. Compression of these nerves can interrupt their function, and the effects can be severe. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage.

Question 19

What causes Cauda Equina Syndrome?

Answer 19

Herniated disk
Bony metastasis
Myeloma
Infection
Fracture
Abscess
Narrowing of the spinal canal.

Question 20

How does Cauda Equina Syndrome present?

Answer 20

Lower motor neurone presentation
Sudden or gradual onset, bilateral but asymmetrical leg symptoms. Loss or motor function in legs, muscle weakness sensory loss.
Saddle, upper inner thigh and perineal numbness
Urinary retention and faecal incontinence.
Urinary overflow incontinence and constipation.
Decrease in reflexes

Question 21

Why is Cauda Equina Syndrome so difficult to diagnose?

Answer 21

Rare and its early symptoms may be similar to symptoms of other conditions. Symptoms associated with cauda equina syndrome may vary in intensity and evolve slowly over time.

Question 22

How would you investigate Cauda Equina Syndrome?

Answer 22

History of symptoms.
Examination e.g may check tone and numbness of anal muscles
MRI 🡪 best method of imaging the spinal cord, nerve roots, intervertebral discs, and ligaments.
Myelogram 🡪 uses contrast dye and CT, show pressure on the cauda equina from herniated discs and other conditions.

Question 23

How would you manage Cauda Equina Syndrome?

Answer 23

Urgent neurosurgical decompression is needed to prevent irreversible loss
Laminectomy for disc protrusions, radiotherapy for tumours, decompression for abscesses.

Question 24

What are the potential lasting effects of Cauda Equina Syndrome?

Answer 24

When patients don’t seek immediate treatment to relieve the pressure 🡪 can result in permanent paralysis, impaired bladder and/or bowel control, loss of sexual sensation, and other problems.
Even with immediate treatment, some patient may not recover complete function. Such as may not know when need to urinate or empty bowels.

Question 25

What is musculoskeletal pain?

Answer 25

Musculoskeletal pain is pain that can affect the bones, muscles, ligaments, tendons, and nerves.
It can be acute (having a rapid onset with severe symptoms) or chronic.
Can be localized in one area, or widespread.

Question 26

What can cause musculoskeletal back pain?

Answer 26

Can be caused by disorders that directly affect the bones, muscles, joints, and ligaments. Such as arthritis, osteoporosis, fractures.
Or can be caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, this type of pain results from habits, such as poor posture.

Question 27

What are the different types of musculoskeletal back pain?

Answer 27

Lower back pain - most common, tension and stiffness to pain and soreness, usually lumbar strain
Upper and middle back pain - problem with the muscles or ligaments, an injury, or a pinched nerve in the spine
Neck pain - stiffness, tightness, sharp pain, reduce the movement, headaches
Buttocks and leg pain - usually sciatica due to a prolapsed disc

Question 28

What are the non-muscular issues that may present as back pain?

Answer 28

Kidney stones - sharp pain in the lower back, usually on one side.
Infection - osteomyelitis, discitis, sacroilitis
Ankylosing spondylitis - worse in the morning
Slipped (prolapsed) disc - back pain and numbness, tingling and weakness in other parts of the body.
Sciatica - pain, numbness, tingling and weakness in the lower back, buttocks, legs and feet.
Pancreatitis - pain can radiate to the back
Spondylolisthesis - bone in the spine slipping out of position
Spinal stenosis - pain or numbness with walking and over time leads to leg weakness and sensory loss.
Cauda equina syndrome
Cancer such as multiple myeloma - night-time pain disturbing sleep
Abdominal aortic aneurysm
Fracture in spine
Pyelonephritis - pain in back or side

Question 29

What are the two major types of spinal injury?

Answer 29

Incomplete 🡪 If the injury is not severe enough to severe the spinal cord, or to severely interfere with function. An individual retains some feeling below the site of injury.
Complete 🡪 all sensation, along with ability to move, are completely lost below the site of the injury.

Question 30

What is Paraplegia?

Answer 30

Refers to paralysis that affects the body from the chest or waist down. Paralysis of both legs.

Question 31

What is Tetraplegia?

Answer 31

Refers to paralysis that affects the cervical spinal cord or the first thoracic vertebra. Paralysis of both leg and both arms.

Question 32

What causes paraplegia and tetraplegia?

Answer 32

Both paraplegia and tetraplegia most often caused by spinal cord injuries. Can be caused by diseases e.g multiple sclerosis.
Most spinal cord injuries caused by, accidents such as car crashes, falls and sports injuries.

Question 33

What are the major consequences of paraplegia?

Answer 33

Impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord.
When paralysis affect the muscles of the chest, diaphragm, and abdomen such as in thoracic 2-6 paraplegia, respiratory function can be affected.

Changes in sexual functionality or libido.
Loss or impediment of bladder and bowel function leading to incontinence
Phantom pains or sensations
Secondary infections
Psychological, anxiety and depression from social isolation, lack of emotional support, increased dependence on others.

Question 34

What are the major consequences of tetraplegia?

Answer 34

Impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord.
When paralysis affect the muscles of the chest, diaphragm, and abdomen such as in thoracic 2-6 paraplegia, respiratory function can be affected.

Changes in sexual functionality or libido.
Loss or impediment of bladder and bowel function leading to incontinence
Phantom pains or sensations
Secondary infections
Psychological, anxiety and depression from social isolation, lack of emotional support, increased dependence on others.

Question 35

How would you manage paraplegia or tetraplegia?

Answer 35

Immediate treatment of spinal cord injuries 🡪 bracing the bony spine to keep it from moving and further injuring the spinal cord.
Steroids and other medications may be used to lessen damage to nerves and nearby tissue.
Recovery and rehabilitation initially in hospital setting.
-Medications
-Surgery
-Intensive physical therapy
-Support groups
-Mobility aids, such as wheelchairs.

Question 36

What is pain in the cervical region like?

Answer 36

Cervical spine: supports the weight of the neck and protects the nerves
Most acute pain here is caused by a muscle, ligament or tendon strain or sprain.
Localised pain that ranges from mild and achy to sharp and debilitating
Pain may occur immediately or after many hours
May be accompanied with stiffness and swelling

Question 37

What is pain in the cervical region usually caused by?

Answer 37

Most chronic pain here is caused by cervical herniated disc or foraminal stenosis pinching a nerve.
May last 2-3 months
Most commonly C6 or C7
Symptoms for pinched nerve at C6: weakness in the biceps and wrist extensors, and pain/numbness that runs down the arm to the thumb

Question 38

What is pain in the thoracic region like?

Answer 38

Upper back pain symptoms: localised sharp pain, achy or throbbing pain which can spread, stiffness, radiating pain to arm, chest, stomach or further down the body, tingling, numbness or weakness.

Question 39

What is pain in the thoracic region usually caused by?

Answer 39

Irritation of the large back or shoulder muscles - spasm and lack of motion
Thoracic herniated disc - pain, numbness, weakness, spascity spreading to leg/s
Compression fractures due to osteoporosis - pain, loss of flexibility and height

Question 40

What is pain in the lumbar region usually caused by?

Answer 40

Osteoarthritis at L3-4 or L4-L5 - back and/or neck stiffness and pain worse in the morning, swelling and warmth, localised tenderness, loss of flexibility
Lumbar herniation (most common at L4-L5 or L5-S1) ‘Sciatica’ - shooting pain and tingling from lower back or buttock and radiating down one leg, numbness
Muscle strain - Localised pain that ranges from mild and achy to sharp and debilitating, may be accompanied by stiffness and swelling
Other - claudication from stenosis, inflammatory pain from ankylosing spondylitis or rheumatoid arthritis, pain that originates from elsewhere like kidney stones and ulcerative colitis

Question 41

What is pain in the sacral region usually caused by?

Answer 41

Sacroiliac joint dysfunction - mild to severe pain that spreads to the hips, buttocks, and/or groin, Sciatic-like pain, stiffness and instability of the pelvis
Pinched nerve at S1 - weakness in the gastrocnemius, causing difficulty with foot push, numbness on the outside of the foot, loss of ankle jerk reflex
Stress fractures and fatigue fractures - sharp and spontaneous pain, aggravated by arching or standing, pain radiates to buttock or thigh, exaggerated back arch
Occur in patients with rheumatoid arthritis or osteoporosis
Coccydynia caused by muscle/ligament strain or trauma - dull and achy pain with some occasional sharp pain, worsening with activity

Question 42

What are the major neurological emergencies and how would you treat them?

Answer 42

Stroke - Aspirin and CT/MRI scan, thrombolytics in the case of an ischaemic stroke
Meningitis - Intravenous antibiotics and fluids, oxygen, steroids if needed
Encephalitis - Antivirals, steroids, plasmapheresis, antibiotics, surgery depending on the cause
Seizures - Buccal Midazolam or rectal Diazepam (sedatives)
Myasthenia Gravis crisis - Oxygen/ventilator, IV immunoglobulin therapy, plasmapheresis
Guillain Barre Syndrome - IV immunoglobulin therapy, plasmapheresis, supportive treatment
Spinal cord compression - MRI, high-dose dexamethasone

Question 43

What are the important aspects of a neurological assessment?

Answer 43

Patient history
Glasgow coma scale
Mental status
Cranial nerves
Motor system
Sensory system
Gait and speech
Examination of the neck

Question 44

What would you ask about in a patient history in a neurological assessment?

Answer 44

Symptoms - time of onset, duration, location
Associated symptoms - headache, numbness, weakness, nausea, vomiting, visual disturbance, altered consciousness, psychological changes
Past medical history - particularly any infections, convulsions or injuries in infancy, childhood or adult life
Systemic enquiry - weight loss/gain, problems with micturition, bowel movements, erectile dysfunction
Social history - smoking, drinking, drugs, occupation
Family history

Question 45

What is the Glasgow Coma scale useful?

Answer 45

Glasgow coma scale is a scale used to give a reliable assessment of a patient’s state of consciousness.

It can be useful to perform multiple times to identify any changes with the patient.

Question 46

What is the Glasgow Coma scale?

Answer 46

Eye opening response - spontanteously, to speech, to pain, no response
Best verbal response - orientated to time/place/person, confused, inappropriate words, incomprehensible sounds, no response
Best motor response - obeys command, moves to localised pain, flexion withdrawal from pain, abnormal flexion, abnormal extension, no response
Best response 15
Comatose patient 8 or less
Totally unresponsive 3

Question 47

What should you assess in a mental state examination?

Answer 47

Appearance - clothing, posture, gait, hygiene, evidence of self-harm
Behaviour - eye contact, facial expression, body language, psychomotor activity, engagement, ability to follow requests
Speech - rate, quantity, tone, volume, fluency and rhythm
Mood (sustained state of inner feelings)
Affect (observable expression of inner feelings)
Thought - speed, flow/coherence, abnormal content, possession
Perception - hallucinations and illusions
Cognition - orientation, attention/concentration, short-term memory
Insight (recognition of problems) and judgement (problem-solving)

Question 48

How would you test the cranial nerves?

Answer 48

Olfactory - Ask about any changes to sense of smell, formal odour exam with recognisable smells
Optic - Snellen’s test, pupillary reflexes, colour vision, fundoscopy
Oculomotor, Trochlear and Abducens - ‘H’ drawn in the air to test eye movement
Trigeminal - Light touch of forehead, cheek, jaw, clench teeth
Facial - Raised eyebrows, closed eyes, blown out cheeks, smiling, pursed lips, closed lips
Vestibulocochlear - Rinne’s and Weber’s tests
Glossopharyngeal and Vagus - Gag reflex, cough, swallow
Accessory - Shrug shoulders with resistance and turn head to the side with resistance
Hypoglossal - Protrusion of the tongue

Question 49

What should you test when testing a patient’s motor system?

Answer 49

Upper and lower limbs
Tone
Power: ranked 0-5 based on ability to contact and overcome gravity and resistance from the examiner
Deep tendon reflexes: categorised as hyperactive (+++), normal (++), sluggish (+) or absent (-)
Superficial tendon reflexes
Examination of coordination

Question 50

What should you test when testing a patient’s sensory system?

Answer 50

Upper and lower limbs
Light touch (tissue or cotton wool) and sharp touch (pinprick)
Temperature (warm and cool on different areas of skin)
Proprioception (test the direction of movement on the distal interphalangeal joint)
Vibration sense (using a tuning fork)
Two-point discrimination (patient asked to identify one or two stimuli)

Question 51

How should you assess a patient’s gait?

Answer 51

Look for any evidence of, for example, hemiparesis, foot drop, ataxic gait, a typical Parkinsonian gait.

Question 52

How would you test someone’s speech?

Answer 52

Look for problems with articulation (dysarthria) ‘West Register Street’
Look for problems with phonation (dysphonia) - laryngeal problems
Look for problems with language function (dysphasia)

Question 53

How would you examine a patient’s neck?

Answer 53

Examine flexion, extension and rotation
Look for Lhermitte’s sign (neck flexion causing the feeling of an electric shock due to a disease in the cervical spinal cord sensory tracts)
Test neck stiffness by asking the patient to place their chin on their chest - inability to do this may be a sign of meningitis or subarachnoid haemorrhage
Listen for any carotid or subclavian bruits