Back Pain Flashcards
(32 cards)
What is spinal cord compression?
Acute spinal cord compression is a neurosurgical emergency.
Rapid diagnosis and management are essential to have the highest chances of preventing permanent loss of function.
Causes of spinal cord compression
Trauma Tumours Prolapsed disc Epidural or subdural haematoma Inflammatory disease Infection Cervical spondylitis myelopathy Spinal manipulation
Features of trauma causing spinal cord compression
Trauma (including car accidents, falls and sports injuries):
o There is usually either vertebral fracture (most common in cervical vertebrae) or facet joint dislocation.
o Complete transection of the spinal cord can occur.
o Hemisection of the spinal cord can occur and is known as Brown-Séquard’s syndrome. It is usually caused by a penetrating trauma.
Features of tumours causing spinal cord compression
o These can include bone tumours, primary or metastatic tumours, lymphomas, multiple myeloma and neurofibromata.
o Acute myelopathy in patients with cancer can also be caused by irradiation, paraneoplastic necrotising myelitis, ruptured intervertebral disc and meningeal carcinomatosis with spinal cord involvement.
Features of prolapsed intervertebral disc causing spinal cord compression
o L4-L5 and L5-S1 are the most common levels for disc prolapse. Large disc herniations can cause cauda equina syndrome
o Cervical disc herniation can also occur.
Features of inflammatory disease causing spinal cord compression
• Inflammatory disease, especially rheumatoid arthritis:
o In rheumatoid arthritis there is often considerable weakness of the ligament that holds the odontoid peg. If this rupture, the atlas can slip forward on the axis and compress the high cervical spine.
Features of epidural or subdural haematoma causing spinal cord compression
• An epidural or subdural haematoma:
o There may be a history of trauma, a recent spinal procedure and/or the patient may be on anticoagulant therapy.
Features of infections causing spinal cord compression
• Infection:
o Spinal infections can be acute or chronic.
o Acute infections are usually bacterial; chronic infections are usually due to tuberculosis or fungal infection.
o Vertebral osteomyelitis, discitis or haematogenous spread of infection can lead to an epidural abscess.
Features of cervical spondylitis causing spinal cord compression
o The ageing process can lead to narrowing of the spinal canal due to osteophytes, herniated discs and ligamentum flavum hypertrophy.
o In advanced stages, it can cause spinal cord compression.
Features of spinal manipulation causing spinal cord compression
o Damage to the spinal cord may be a very rare complication of chiropractic or osteopathic manipulation of the neck.
Red flag signs suggesting spinal compression?
• Red flags that suggest spinal compression include:
o Insidious progression.
o Neurological symptoms: gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function.
o Neurological signs:
- Lhermitte’s sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs.
- Upper motor neurone signs in the lower limbs (Babinski’s sign: up-going plantar reflex, hyperreflexia, clonus, spasticity).
- Lower motor neurone signs in the upper limbs (atrophy, hyporeflexia).
- Sensory changes are variable, with loss of vibration and joint position sense more evident in the hands than in the feet.
Presentation of spinal cord compression
• Clinical features depend upon the extent and rate of development of cord compression.
o Motor symptoms can include ready fatigue and disturbance of gait.
o Cervical spine lesions can produce quadriplegia. Injury above the level of C3, C4, C5 (the segmental level of the phrenic nerve) cause paralysis of the diaphragm and artificial ventilation is required.
o Sensory symptoms can include sensory loss and paraesthesia. Light touch, proprioception and joint position sense are reduced.
o There can be root pain in the legs.
o Tendon reflexes are typically:
Increased below the level of injury and/or compression.
Absent at the level of injury and/or compression.
Normal above the level of injury and/or compression.
o Sphincter disturbances - late features of cervical and thoracic cord and/or compression.
o There may be loss of autonomic activity with lack of sweating below the level, loss of thermoregulation and drop in peripheral resistance causing hypotension.
Investigations for spinal cord compression
• Haemoglobin and haematocrit levels should be measured initially and monitored serially to monitor blood loss.
• Blood tests:
o FBC – bone marrow infiltration can lead to bone marrow suppression with anaemia and thrombocytopenia
o Bone profile – hypercalcaemia can occur with bone metastases and may be asymptomatic
o U&Es – especially important if hypercalcaemia is found
o LFTs – as a marker for other sites of metastatic disease
- Renal function and electrolytes: dehydration.
- MRI scan of the whole spine.
- CT scan and CXR to look for signs of metastasis in metastatic spinal cord compression (MSCC)
How is early detection of MSCC facilitated?
- Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC.
- Offer information (for example, in the form of a leaflet) to patients and their families and carers which explains the symptoms of MSCC, and advises them (and their healthcare professionals) what to do if they develop these symptoms.
When should the GP contact the MSCC coordinator regarding a cancer patient?
• Contact the MSCC coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:
o pain in the middle (thoracic) or upper (cervical) spine
o progressive lower (lumbar) spinal pain
o severe unremitting lower spinal pain
o spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)
o localised spinal tenderness
o nocturnal spinal pain preventing sleep.
• Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:
o neurological symptoms including radicular pain (band-like pain), any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
o neurological signs of spinal cord or cauda equina compression.
Management of spinal cord compression
- Nurse the patient flat with the spine in neutral alignment (eg, using logrolling or turning beds) until spinal stability and neurological stability are ensured.
- Give a course of dexamethasone unless contra-indicated until a definitive treatment plan is made (MSCC as well).
- Insert a catheter to manage bladder dysfunction.
- Use breathing exercises, assisted coughing, and suctioning to clear airway secretions.
- Neurosurgical stabilisation surgery (MSCC)- All patients with cord compression, actual or imminent, or vertebral instability should be discussed with the neurosurgeons. There is evidence that neurosurgical intervention with decompression and stabilisation improves the chance of the patient retaining mobility
- Prophylaxis of VTE (enoxaparin)
- Prevention of gastric stress ulcers (PPI)
- Maintenance of volume and BP
- Bisphosphonates should be offered to all patients with vertebral involvement from myeloma and breast cancer and to patients with prostate cancer in whom conventional analgesia is inadequate.
- Specialised pain control procedures may be needed for intractable pain (eg, epidural analgesia).
- If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or before other neurological deterioration occurs, and ideally within 24 hours.
- Definitive treatment may be using surgery (e.g., laminectomy, posterior decompression ± internal fixation) or using radiotherapy.
Which medication should be given with dexamethasone?
o High dose dexamethasone is usually started to reduce any additional inflammation around the metastatic deposit and can improve neurological function if actual cord compression is identified.
o Dexamethasone is the most commonly used drug, given orally at a dose up to 16mg a day (in two doses, preferably morning and lunch).
o Always consider gastro-prevention with a PPI such as lansoprazole 30m daily when starting high dose steroids.
Complications of spinal cord compression
- Pressure sores
- Hypothermia
- Potential lung complications include aspiration, pneumonia, ARDS, atelectasis.
- Depression.
- Paralysis
What is the role of calcium in the body?
- Calcium has a vital role to play in the effective working of the majority of cells in the body and it is therefore important that the optimal level be maintained by the body.
- A reduction in serum calcium can stimulate parathyroid hormone (PTH) release which may then increase bone resorption, increase renal calcium reabsorption, and stimulate renal conversion of 25-hydroxyvitamin D3, to the active 1,25-dihydroxyvitamin D3, which then will increase intestinal calcium absorption.
- These mechanisms restore the serum calcium to normal and inhibit further production of PTH and 1,25-dihydroxyvitamin D3
What is corrected calcium level?
- The level for serum calcium is frequently given by laboratories as both an uncorrected level and a corrected level which has allowed for changes in albumin levels.
- It is only the ionised (unbound) calcium, which is physiologically important, taking part in cellular activities such as neuromuscular contraction, coagulation and other cellular activities
Presentation of hypercalcaemia at levels<2.8 mmol/L
• At levels <2.8 mmol/L: o Polyuria and polydipsia o Dyspepsia - due to calcium-regulated release of gastrin o Depression o Mild cognitive impairment
Presentation of hypercalcaemia at levels<3.5mmol/L
• At levels <3.5 mmol/L: o All of the previous plus o Muscle weakness o Constipation o Anorexia and nausea o Fatigue
Presentation of hypercalcaemia at levels>3.5mmol/L
• At levels >3.5 mmol/L o All of the previous plus o Abdominal pain o Vomiting o Dehydration o Lethargy o Cardiac arrhythmias- shortened QT interval o Coma o Pancreatitis
What happens when hypercalcaemia is long-standing?
• If the hypercalcaemia is long-standing, calcium may be deposited in soft tissues or may result in stone formation - e.g., nephrocalcinosis, nephrolithiasis or chondrocalcinosis.
