Clinical Reasoning Case Study 2

Question 1

Types of Back Pain

Answer 1

Nocioceptive Pain, Somatic Referred Pain, Radicular Pain, Radiculopathy

Question 2

Nocioceptive Pain

Answer 2

Pain that is evoked by noxious stimulation of structures or tissues.

-Noxious: Damage to tissue, does not necessarily cause pain. (Usually a dull, achy pain if there is pain present)

Question 3

Somatic Referred Pain

Answer 3

-Produced by noxious stimulation of nerve endings within spinal structures (discs, zygopophaseal joints, SI joints)
-Pain spreads into the lower limbs, lies in the somatic tissues of the lumbar spine (center over gluteal region/proximal thigh and extend to the foot)
-Dull, aching, gnawing and sometimes expanding pressure

Question 4

Radicular Pain

Answer 4

-Pain evoked by ectopic discharges emanating from a dorsal root or its ganglion
-Disc herniation is the most common cause
-Inflammation of affected nerve (or previously inflamed)
-Only type of pain produced by stimulating nerve roots,
-Travel the length of the lower limb
-Pain is lancinating, shocking, electric

Question 5

Radiculopathy

Answer 5

-Blockage of spinal nerve or it’s nerve roots
-Causes numbness (dermatomal), weakness (myotomal), diminished reflexes
-Not defined by pain

Question 6

Somatic referred pain is often misdiagnosed as ___________

Answer 6

Radicular pain

Question 7

Categories of Disc Herniation

Answer 7

Disc Protrusion, Disc Sequestration, Disc Extrusion

Question 8

Disc Protrusion

Answer 8

Depth of the herniation is less than the base of the herniation

Question 9

Disc Extrusion

Answer 9

Depth of the herniation is larger than the base of the Herniation

Question 10

Disc Sequestration

Answer 10

Extruded Disc has no continuity with the disc of origin

Question 11

Risk factors of disc herniation

Answer 11

Genetic, lumbar loads, exercise, smoking, obesity, taller than 6’3”

Question 12

Herniated Disc & Sciatica Recovery

Answer 12

-55-73% w/o surgery after 12 weeks (depending on study)
-Surgery and conservative treatment are similar, although surgery helps with pain relief sooner

Question 13

Somatic referred pain is ________ but radicular pain is not

Answer 13

Common

Question 14

With respect to clinical management, imaging is justified for the investigation of ________ and _________. The same cannot be said for __________

Answer 14

Radicular pain and radiculopathy; somatic referred pain

Question 15

Nocioceptive back pain and somatic referred pain involved nerve injury (T/F)

Answer 15

False

Question 16

Allodynia is not a typical feature of radicular pain or radiculopathy, unless there is true nerve damage and neuropathy rather than simply compression or inflammation.

Answer 16

True

Question 17

A patient who is distressed by a pain shooting down the limb, cannot lie comfortably, and on examination has numbness or weakness in the leg

Answer 17

Radicular pain and radiculopathy

Question 18

A patient with aching pain in the back, which spreads to the buttocks and thigh, but no lancinating pain and no neurological symptoms

Answer 18

Nocioceptive back pain and somatic referred pain

Question 19

What is the role of the disc

Answer 19

Motion, force distribution, shock absorption

Question 20

Why do disc injuries occur?

Answer 20

Underprepared for the load that is
placed on them.
- Tissues cannot withstand the
stress demands, causing them to
fail.

Question 21

DDD

Answer 21

• Normal age-related change in the spine
• Discs lose water content as we age - Because of this, force is transmitted differently into tissues
• Failure occurs
• Discs become much more rigid as we age, which is why disc herniations are less common in people over the age of 60

Question 22

Criteria of the presence of cervical radiculopathy

Answer 22

Positive upper limb tension test, involved-side cervical rotation ROM less than 60 degrees, positive distraction test, positive spurlings test A