Back Pain and Spinal Disorders

Question 1

What are the causes of mechanical back pain?

Answer 1

• Lumbar strain/sprain
• Degenerative discs/joints (increase with flexion, sitting, sneezing)
• Degenerative facets/joints (more localised, increased with extension)
• Compression fractures (radiates in belt around chest/abdomen, sudden onset, associated osteoporosis)

Question 2

What are the differences between inflammatory and mechancal back pain?

Answer 2

Question 3

What are the red flags for back pain?

Answer 3

• Trauma
• Unexplained weight loss
• Neurological symptoms (saddle anaesthesia, absent anal tone, lower limb weakness)
• Age >50
• Fever
• IVDU
• Steroid use
• History of cancer (prostate, renal, breast, lung)

Question 4

What are yellow flags for back pain? (ABCDEFW)

Answer 4

• Attitudes – towards the current problem
• Beliefs – misguided belief that they have something serious
• Compensation – awaiting payment for an accident/RTA?
• Diagnosis – inappropriate communication, patients misunderstanding what is meant
• Emotions – other emotional difficulties (i.e. depression, anxiety)
• Family – either over bearing or under supportive
• Work relationship

Question 5

What are the features of disc prolapse?

Answer 5

• Herniated nucleus pulposus
• May be acute
• Straight-leg raise test positive
• Leg pain in dermatomal distribution
• Reduced reflexes
• Sciatica and radiculopathy
• Can lead to Cauda equina syndrome (bilateral sciatica, saddle anaesthesia, reduced anal tone, needs urgent neurosurgical review)

Question 6

What are the features of infective discitis?

Answer 6

• Fever, weight loss
• Constant back pain
• Immunosuppressed, diabetes, IVDU
• Most commonly staphylococcus aureus
• IV antibiotics and surgical debridement

Question 7

What are the features of malignany back pain?

Answer 7

• History of malignancy (lung, prostate, thyroid, kidney, breast)
• Constant pain, worse at night
• Systemic symptoms

Question 8

What are the clinical and radiological criteria for ankylosing sponditis?

• Low back pain and stiffness for >3 months, improves with exercise but not relieved by rest
• Limitation of motion of lumbar spine and chest expansion
• Sacrolitis grade ≥2 bilaterally or 3-4 unilaterally

Question 9

What are the features of spondylolisthesis?

Answer 9

• Pars-interarticularis defect, asymptomatic in most
• Pain may radiate to posterior thigh
• Increase with extension

Question 10

What are the features of spinal stenosis?

Answer 10

• Anatomical narrowing spinal canal
• Congenital and/or degenerative
• Often presents with ‘claudication’ in legs/calves (worse walking, rest in flexed position)

Question 11

What conditions cause referred pain in the back?

Answer 11

• Aortic aneurysm
• Acute pancreatitis
• Peptic ulcer disease
• Acute pyelonephritis/renal colic

Question 12

Anatomy of the spinal cord in relation to cauda equina

Answer 12

• The spinal cord tapers and ends at the level between the first and second lumbar vertebrae in an average adult. The most distal bulbous part of the spinal cord is called the conus medullaris, and its tapering end continues as the filum terminale. Distal to this end of the spinal cord is a collection of nerve roots, which are horsetail-like in appearance and hence called the cauda equina

Question 13

Features of cauda equina syndrome

Answer 13

• Severe lower back pain
• Pain, numbness or weakness in one or both legs
• Loss of or altered sensation in legs, buttocks, inner thighs, backs of legs or feet
• Recent issue with bowel/bladder function (retention or incontinence)
• Sexual dysfunction that has come on suddenly

Question 14

Investigation and management of cauda equina syndrome

Answer 14

• Investigation
  
  • Hx and examination (strengthm reflexes, sensation, stability, alignment and motion)
  • MRI
  • Myelogram
  • CT
• Management
  
  • Aim to relieve pressure on nerves
  • Immobilisation
  • Decompressive/stabilisation surgery with 48 hours
  • IV corticosteroids
  • Antibiotics if epidural abscess
  • Radiotherapy if malignant compression
• Complications
  
  • Paralysis of the legs
  • Loss of bladder and bowel control
  • Loss of sexual function

Question 15

Presentation of mechanical back pain

Answer 15

• Obesity, stress and psychiatric comorbidities
• Hx of lower back pain
• Hx of prior treatment
• Pain radiation does not extend beyond knee
• Absence of red flag symptoms
• Absence of fever, fluctuance, exquisite tenderness on palpation
• Sensory, motor and deep tendon reflex examinations normal
• Negative straight or crossed straight leg raise

Question 16

Management of mechanical back pain

Answer 16

• Patient education and return to normal activity
• Self care temperature treatments
• Analgesics (paracetamol > NSAIDs > opoids)
• Muscle relaxants (i.e. cyclobenxaprine)
• Lumbar spine manipulation
• Active physiotherapy

Question 17

Spinal nerve root impingement presentation

Answer 17

• The pain occurs when the spinal cord or spinal nerve is irritated by the pressure or a chemical reaction from the displaced herniated material.
• Loss of function
• Leg numbness
• Leg parasthesia
• Absence of examination findings
• Leg pain when walking
• Activity related back pain
• Stooped posture when walking
• Bladder/bowel dysfunction
  *

Question 18

Causes of nerve root impingement

Answer 18

• Herniated disc, when a disc protrudes, compressing the nerve root
• Sciatica
• Degenerative disc disease
• Bone spurs
• Tumors of the spine
• Osteoarthritis or spinal arthritis
• Spinal stenosis, a painful condition when the spinal canal narrows
• Compression fractures
• Spondylolisthesis, when a vertebra moves and rests on the vertebra below
• Scoliosis caused by an abnormal curve in the spine
• Diabetes, caused by altered nerve blood flow
• Cauda equine syndrome, an uncommon but serious condition when nerve root compression affects the pelvic organs and lower extremities

Question 19

Managment of nerve root impingement

Answer 19

• Non-steroidal drugs, such as ibuprofen, aspirin or naproxen
• Oral corticosteroids or injectable steroids
• Narcotic pain medications
• Physical therapy
• Soft cervical collar
• Ice and heat application
• Surgery in some cases (repair of a herniated disc, widening of spinal canal space, removing bone spur, fusing bones)

Question 20

Management of malignant back pain

Answer 20

• Neutral spine alignment (nursed lying flat)
• Manage circulatory and respiratory function (i.e. VTE prophylaxis, clearing lung secretions)
• Managing bowel and bladder function (i.e. catheterise)
• Monitor for pressure ulcers
• Mobilise as able
• Corticosteroids
• Radiotherapy
• Surgery
• Rehabilitation and transition to care at home

Question 21

American Spinal Injury Association (ASIA) Impairment Scale (functional impairment as a result of SCI)

Answer 21

• Grade A = Complete. No sensory or motor function is preserved in the sacral segments S4-5.
• Grade B = Sensory Incomplete. Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-5 (LT or PP at S4-5 or DAP), and no motor function is preserved more than three levels below the motor level on either side of the body.
• Grade C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.
• Grade D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.
• Grade E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

Question 22

Radiological features of scoliosis

Answer 22

• Levoscoliosis - curvature to the left
• Dextroscoliosis - curvature to the right
• Comment on:
  
  • Presence of structural osseous abnormalities (wedging, segmentation)
  • Major and minor curves
  • Apex
  • End vertebrae
  • Neutral vertebrae
  • Stable vertebrae
  • Sagital and coronal balance (relationship of C7 to S1)