back pain

Question 1

risk factors for lumbar disc herniation and most common level? and brief classify consequence?

Answer 1

common levels are L4-L5 & L5-S1

male, old age, sedentary lifestyle, lifting heaving objects, obesity, smoking

posterolateral: sciatica
central: cauda equina

Question 2

presentation of sciatica?

Answer 2

majority of pts are asymptomatic

sciatica: shooting, electric-like pain from buttock to posterior thigh and calf. worse with sitting, coughing, sneezing but better with standing.
numbness, tingling or burning along distribution of sciatic nerve

Question 3

red flags of back pain?

Answer 3

-age <18 or >50 (malignancy)
-IV drug abuser (spinal infection)
-fever, night sweats, weight loss (malignancy)

-hx of cancer, TB (indian), HIV (spinal infection/malignancy)
-saddle anesthesia, bowel bladder or sexual dysfunction (cauda equina)

-constant back pain not relieved even at night and for more than 6wks
-progressive neurologic deficits or BILATERAL limb involvement (cancer)

Question 4

diagnosis of lumbar disc herniation?

Answer 4

CLINICAL DX

-xray (narrow disc spaces)
-MRI is done ONLY when red flags are present or failure to improve after 6wks
also order CRP, ESR, bone scan, abdomen US and ct angio (AAA)

Question 5

management of sciatica and cauda equina?

Answer 5

sciatica: bed rest, physiotherapy, NSAIDs. no improvement -> nerve root epidural steroid injection

if cauda equina, failure of non operative management, progressive neurologic deficits -> laminotomy and discectomy

Question 6

causes of cauda equina?

Answer 6

disc herniation, TB, lymphoma, trauma

Question 7

symptoms of cauda equina?

Answer 7

present acutely or gradually in pt with hx of back pain. back pain is not essential in presentation

motor: uni or bilateral LL weakness and hyporeflexia

sensory: saddle and perineal anesthesia (S2-S5), uni or bilateral sciatica and sensory deficits in LL

autonomic: bladder, bowel, sexual dysfunction (urine retention, fecal incontinence, impotence)

Question 8

conus medullaris syndrome? diagnosis of cauda equina?

Answer 8

present as mix of upper and lower motor neuron lesion (hyperreflexia and fasciculations)

Dx is clinical but use MRI if needed