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.