Trauma and orthopaedics (7): Vertebral conditions Flashcards
lower back pain
Non-specific or mechanical lower back pain refers to the majority of patients who do not have a specific disease causing their lower back pain.
presentation and triggers of mechanical back pain
presentation
Pain when the spine is loaded (sitting, standing, not lying)
Worse with exercise relieved by res
sciatica
symptoms associated with irritation of the sciatic nerve
acute low back pain should improve within
1-2 weeks
sciatica should improve within
4-6 weeks
There are several challenges with managing patients with lower back pain:
- Identifying serious underlying pathology
- Speeding up recovery
- Reducing the risk of chronic lower back pain
- Managing symptoms in chronic lower back pain
- can really affect patients quality of life
causes of mechanical back pain
- Muscle or ligament sprain
- Facet joint dysfunction
- Sacroiliac joint dysfunction
- Herniated disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Scoliosis (curved spine)
- Degenerative changes (arthritis) affecting the discs and facet joints
causes of neck pain
- Muscle or ligament strain (e.g., poor posture or repetitive activities)
- Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
- Whiplash (typically after a road traffic accident)
- Cervical spondylosis (degenerative changes to the vertebrae)
the sciatic nerve
- The spinal nerves L4 – S3 come together to form the sciatic nerve.
- The sciatic nerve exits the posterior part of the pelvis through the greater sciatic foramen, in the buttock area on either side.
- It travels down the back of the leg. At the knee, it divides into the tibial nerve and the common peroneal nerve.
where does the sciatic nerve supply sensation
lateral lower leg and the foot.
where does the sciatic nerve supply motor function
posterior thigh, lower leg and foot.
presentation of sciatica
- unilateral pain from the buttock radiating down the back of the tight to below the knee or feet
- electric or shooting pain
- parasethesia, numbness and motor weakness
causes of sciatic a
lumbosacral nerve root compression by
- Herniated disc (prolapsed)
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Spinal stenosis
bilateral sciatica
ed flag for cauda equina syndrome.
key symptoms in history for sciatica
SOCRATES
- Major trauma (spinal fracture)
- Stiffness in the morning or with rest (ankylosing spondylitis)
- Age under 40 (ankylosing spondylitis)
- Gradual onset of progressive pain (ankylosing spondylitis or cancer)
- Night pain (ankylosing spondylitis or cancer)
- Age over 50 (cancer)
- Weight loss (cancer)
- Bilateral neurological motor or sensory symptoms (cauda equina)
- Saddle anaesthesia (cauda equina)
- Urinary retention or incontinence (cauda equina)
- Faecal incontinence (cauda equina)
- History of cancer with potential metastasis (cauda equina or spinal metastases)
- Fever (spinal infection)
- IV drug use (spinal infection)
key findings on examination for sciatica
- Localised tenderness to the spine (spinal fracture or cancer)
- Bilateral neurological motor or sensory signs (cauda equina)
- Bladder distention implying urinary retention (cauda equina)
- Reduced anal tone on PR examination (cauda equina)
special test for sciatica
sciatic stretch test
The patient lies on their back with their leg straight. The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees). Then the examiner dorsiflexes the patient’s ankle. Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. Symptoms improve with flexing the knee.
cancers which may cause bone pain
PoRTaBLe mnemonic
- Po – Prostate
- R – Renal
- Ta – Thyroid
- B – Breast
- Le – Lung
investigation for mechanical lower back pain
can be diagnosed clinically and do not require further investigations.
othe rinvestigations for lower back pain/sciatica
Generally, patients with mechanical/non-specific lower back pain can be diagnosed clinically and do not require further investigations.
X-rays or CT scans can be used to diagnose spinal fractures.
An emergency MRI scan is required in patients with suspected cauda equina (within hours of the presentation).
investigations for suspected ankylosing spondylitis
- Inflammatory markers (CRP and ESR)
- X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease)
- MRI of the spine (may show bone marrow oedema early in the disease)
management of acute lower back apin
- if cauda equina suspected- same day urgent MRI and referral to orthopaedics
- inflammatory markers and urgent rheumatology review if ankylosing spondylitis
- spinal injury suspected- full in line spinal immobilisation- CT scan
management of mechanical back pain
- Self-management
- Education
- Reassurance
- Analgesia
- Staying active and continuing to mobilise as tolerated
Additional options for patients at medium or high risk of developing chronic back pain include:
- Physiotherapy
- Group exercise
- Cognitive behavioural therapy
analgesia for back pain
- NSAIDs (e.g., ibuprofen or naproxen) first-line
- Codeine as an alternative
- Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
They specifically state not to use opioids, antidepressants, amitriptyline, gabapentin or pregabalin for low back pain.
option for patient with chronic low back pain originating in the facet joints
Radiofrequency denervation
management of sciatica
initial management same as acute low back pain
They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of:
- Amitriptyline
- Duloxetine
Specialist management options for chronic sciatica include:
- Epidural corticosteroid injections
- Local anaesthetic injections
- Radiofrequency denervation
- Spinal decompression
Acute spinal cord compression (ASCC)
is a surgical emergency requiring immediate neurosurgical treatment
caused by any pathology that leads to compression of the spinal cord.
causes of ASCC
- neoplastic
- traumatic
- infective
- disc prolapse
- spinal stenosis (if central canal)
neoplastic causes of ASCC
Metastatic spinal cord compression (MSCC) is the most common aetiology
- from the primary malignancies of thyroid, lung, breast, renal, and prostate;
Primary bone tumours, as well as haematological malignancies (e.g. myeloma) can also cause ASCC
traumatic causes of ASCC
- Typically via vertebral fracture or facet joint dislocation (although complete severance of the cord is possible)
infective causes of ASCC
- Infections resulting in abscess formation can cause compression on the spinal cord; chronic infections are typically seen with tuberculosis and fungal infections
disc prolapse as a cause of ASCC
- This is a rare cause of spinal cord compression, as lumbar disc herniation typically causes compression of the cauda equina inferior to the spinal cord
Prolapsed Intervertebral disc (Slipped disc)
Protrusion of the nucleus pulposus with impingement into the spinal canal
four stages of dics herniation
- Prolapse: protrusion of the nucleus pulposus with slight impingement into the spinal canal (contained)- SCIATICA
- Extrusion: nucleus pulposus breaks through annulus fibrosus, but remains within the disc space.
- Sequestration: nucleus pulposus breaks through annulus fibrosus and separates from the main body of the disc in the spinal canal
four stages of disc herniation
- Prolapse: protrusion of the nucleus pulposus with slight impingement into the spinal canal (contained)- SCIATICA
- Extrusion: nucleus pulposus breaks through annulus fibrosus, but remains within the disc space.
- Sequestration: nucleus pulposus breaks through annulus fibrosus and separates from the main body of the disc in the spinal canal
investigation for disc prolapase
MRI
Natural History of Prolapsed
Intervertebral Disc
Occurs in 30 to 50 year olds
Natural history = 90% resolve by 3 months
Most commonly occurs at L4/5 or L5/S1
Usually herniates paracentrally, causing compression of spinal nerve roots
presenation of spinal cord compression
- sensation and proprioception impaired
- pain
- weakness
- upper motor neurone signs
- hypertonia
- hyperrefelxia
- babinski sign
- clonus
investigation of ASCC
The gold standard investigation for a suspected ASCC is an MRI of the whole spine (Fig. 2). NICE guidelines recommend the imaging should be carried out within a week if spinal metastases are suggested and within a day if the cord is believed to be compressed.
Routine blood tests will be helpful, especially if the underlying cause is not apparent. Given the high chance of surgical intervention if ASCC is present, a Group & Save and clotting screen should also be taken.
management of ASCC caused by malignancy
high dose corticosteroids
oncological input
neurosurgery is definitive treatment for MSCC via decompression
→ poor prognosis- usually metastatic
spinal stenosis
narrowing of part of the spinal canal, resulting in compression of the spinal cord or nerve roots
- can be a cause of cord compression
- cervical or lumbar (most common)
spinal stenosis is usually due to
degenerative changes in the spine
>60yo
types of spinal stenosis
- Central stenosis – narrowing of the central spinal canal
- Lateral stenosis – narrowing of the nerve root canals
- Foramina stenosis – narrowing of the intervertebral foramina
causes of spinal stenosis
- Congenital spinal stenosis
- Degenerative changes, including facet joint changes, disc disease and bone spurs
- Herniated discs
- Thickening of the ligamenta flava or posterior longitudinal ligament
- Spinal fractures
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Tumours
presentation of spinal stenosis
- gradual onset (as opposed to cauda equina or sudden disc herniation with cord compression)
- symptoms may be subtle with mild compression
- severe compression can present with features of cauda equina (requiring emergency management)
- radiculopathy- intermittent neurogenic claudication
intermittent neurogenic claudication
- Lower back pain
- Buttock and leg pain
- Leg weakness
The symptoms are absent at rest and when seated but occur with standing and walking. Bending forward (flexing the spine) expands the spinal canal and improves symptoms. Standing straight (extending the spine) narrows the canal and worsens the symptoms.
radiculopathy
refers to compression of the nerve roots as they exit the spinal cord and spinal column, leading to motor and sensory symptoms.
Lateral stenosis and foramina stenosis in the lumbar spine tends to cause symptoms of
sciatica.
investigations for spinal stenosis
MRI is the primary imaging investigation for diagnosing spinal stenosis.
Investigations to exclude peripheral arterial disease (e.g., ankle-brachial pressure index and CT angiogram) may be appropriate where symptoms of intermittent claudication are present.
management of spinal stensois
- Exercise and weight loss (if appropriate)
- Analgesia
- Physiotherapy
- Decompression surgery where conservative treatment fails (with variable results)
surgical manageemnt of spinal stensois
Laminectomy refers to the removal of part or all of the lamina from the affected vertebra. The laminae are the bony parts that form the posterior part of the vertebral foramen (forming the spinal canal) and attaches to the spinous process.
cauda equina
surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed.
It requires emergency decompression surgery to prevent permanent neurological dysfunction. However, even with immediate decompression, patients may still not regain full function.
when does the cauda equina start
spinal cord terminates at around L1/L2
The nerves of the cauda equina supply:
- Sensation to the perineum, bladder and rectum
- Motor innervation to the lower limbs and the anal and urethral sphincters
- Parasympathetic innervation of the bladder and rectum
causes of cauda equina
In cauda equina syndrome, the nerves of the cauda equina are compressed. There are several possible causes of compression, including:
- Herniated disc (the most common cause)
- Tumours, particularly metastasis
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Abscess (infection)
- Trauma
red flags for cauda equina
- Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
- Loss of sensation in the bladder and rectum (not knowing when they are full)
- Urinary retention or incontinence
- Faecal incontinence
- Bilateral sciatica
- Bilateral or severe motor weakness in the legs
- Reduced anal tone on PR examination
red flags for cauda equina
- Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
- Loss of sensation in the bladder and rectum (not knowing when they are full)
- Urinary retention or incontinence
- Faecal incontinence
- Bilateral sciatica
- Bilateral or severe motor weakness in the legs
- Reduced anal tone on PR examination
A common way people ask about saddle anaesthesia when taking a history is to ask
“does it feel normal when you wipe after opening your bowels?”
management of cauda equina
- Immediate hospital admission
- Emergency MRI scan to confirm or exclude cauda equina syndrome
- Neurosurgical input to consider lumbar decompression surgery
prognosis of cauda equina
Surgery should be performed as soon as possible to increase the chances of regaining function. Even with early surgery, patients can be left with bladder, bowel or sexual dysfunction. Leg weakness and sensory impairment can also persist.
