What may be some suspicious features, or red flags, of back pain?
- Systemic upset - Fevers, night sweats, weight loss, fatigue and malaise
- New back pain in the elderly (>60)
- Back pain in the young (<20)
- Pain which is constant, severe or worse at night
- Saddle anaesthesia
- Bladder/bowel upset
- History of cancer (any)
- History of steroids
What is saddle anaesthesia?
Loss of sensation restricted to the area of the buttocks, perineum and the inner thighs
What does testing the L1/2 myotome involve?
What does testing the L3/4 myotome involve?
What does testing the L5 myotome involve?
What does testing the S1/2 myotome involve?
(It can often be hard to pick up weakness here, a good way to test is to ask the patient to go on their tip toes)
What is the gold standard investigation for back pain?
What is the problem with using MRI for back pain?
It can result in many false positives
Abnormalities are common, but they often don't cause any problems
What is a diagnostic facet injection?
An injection of steroids in the facet joint to test if there is improvement
On MRI, what is the appearance of disc inflammation?
What is sciatica?
Buttock and/or leg pain in a specific dermatomal distribution coupled with neurological disturbance of the L4, L5 or S1 nerve roots
Pain radiates to the sensory aspect of the sciatic nerve
When surgery is undertaken for a prolapsed disc, what is the aim of the surgery?
To reduce leg pain
Why will surgery only be considered after 3 months of no improvement for a prolapsed disc?
- There is no long term benefit so rushing into surgery is pointless
- The patient must get back to work as their life will be impacted after 3 months
- There are risks to surgery so it should not be rushed into
- Most (70%) cases settle by themselves within 3 months
What is the first line management of a prolapsed disc and associated back pain?
- Short bed rest - only when really required
- Anti-inflammatories +/- muscle relaxant (diazepam)
- Early mobilisation (potentially with physio)
- Return to normal activity
What is the second line management of back pain associated with a prolapsed disc?
- TENS/psychologist/pain clinic
- Complementary therapies
- Surgery (rare)
Why is cauda equina syndrome an emergency?
There may be limited time (<48 hours) to treat
How must spinal fractures be dealt with initially?
- Deal with other injuries
How can secondary spinal cord damage occur?
- Thrombosis of small vessels
- Venous obstruction
What are the 2 main patterns of spinal cord injury?
What are the three main types of incomplete spinal cord injury?
- Central cord injury
- Anterior cord injury
How does a central spinal cord injury typically occur?
Anterior cord injuries are usually seen after what?
What are the worst problems that cause secondary damage to a spinal cord?
- Undue movement
- Inappropriate surgery
How should ankylosing spondylitis be initially managed?
- Immobilise in natural position (no collars)
- Mandatory CT
What are the 4 types of scoliosis?
- Early onset
- Late onset
What is Heuter-Volkmann's law?
Increased pressure across an epiphyseal growth plate inhibits growth
Secondary scoliosis can result from what?
- Neuromuscular problems
- Spina bifida
What is spondylolysis?
Defect in the pars interarticularis of vertebrae
What is spondylolisthesis?
Forward slippage of one vertebrae onto another
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms
What are causes of mechanical back pain?
- Poor posture
- Poor lifting technique
- Lack of physical activity
- Degenerative disc prolapse
- Factet joint OA
What is spondylosis?
Intervertebral discs lose water content with age which causes less cushioning and secondary OA due to increased facet joint pressure
What is the main treatment for mechanical back pain?
When would spinal stabilisation surgery be indicated for mechanical back pain?
- A single level is affected by OA or instability
- The pain has not improved despite physio and conservative management
- There are no secondary gains from surgery e.g. compensation claim
When does an acute tear in the out annulus fibrosis typically occur?
When there is a tear in the annulus fibrosis of a intervertebral disc, when is the pain characteristically worse?
Why is pain severe with acute disc tear?
The periphery of the disc is richly innervated
What are the mainstay of treatment for acute disc tear?
Analgesia and physiotherapy
The nucleous pulposus may herniate through a tear in the annulus fibrosis which can impinge on nerve roots causing what?
- Pain in a dermatomal distribution
- Reduced power in a myotomal distribution
Where are the most common sites for disc heriation/prolapse to occur?
L4, L5 and S1 nerve roots
How can the radicular pain in disc prolapse be described?
Neuralgic burning or severe tingling pain whichradiates to the back of the thigh to below the knee
An L3/4 disc prolapse leads to __ root entrapment which causes pain down to the _________ _________, loss of power to which muscles and a reduction in which reflex?
An L4/5 disc prolapse leads to __ root entrapment which causes pain down to pain down the _________ of the foot and loss of power to which muscles?
Extensor hallucis longus and tibialis anterior
An L5/S1 disc prolapse leads to __ root entrapment which causes pain down to the _________ of the foot, loss of power _________ and a reduction in which reflex?
What are the treatment options for sciatia?
- Maintaining mobility
- Drugs for neuropathic pain (gabapentin, pregabalin, amitriptyline)
- Surgery (for very few cases)
Why does OA sometimes lead to sciatica?
Osteophyte formation can result in osteophytes impinging on nerve roots causing sciatica
What is the treatment for OA induced sciatica?
Surgical decompression with trimming of impinging osteophytes
What is spinal stenosis?
Narrowing of the spinal canal due to a bulging ligamentum flavum, osteophytes, bulging discs atc
Which age of patient is most likely to suffer from spinal stenosis and what is the classic complaint?
Pain in legs when walking (claudication)
How is claudication induced by spinal stenosis different from claudication induced from PVD?
- The claudication distance is inconsistent
- The pain is burning rather than cramping
- Pain is less when walking uphill as this creates more space in the spinal canal
- Pedal pulses are preserved (dorsalis pedia, tibialis posterior)
When may surgery be indicated for spinal stenosis?
- When conservative management fails e.g. weight loss, physiotherapy, analgesia
- There is MRI evidence of stenosis
What causes cauda equina syndrome?
A very large central disc prolapse which compresses all the nerve roots of the cauda equina
Why is cauda equina syndrome an emergency?
The affected root control urination and defaecation
Prolonged compression can cause permanent nerve damage
What are the classic signs of cauda equina syndrome?
- Bilateral leg pain
- saddle anaesthesia
- Urinary retention is more common than incontinence
- Faecal incontinence/constipation
Which tests are essential in a patient with suspected cauda equina syndrome?
- Rectal examination (PR)
- MRI (determines level of prolapse)
New back pain in people over 60 is considered a red flag, why is this?
Older people are at higher risk of neoplasia, especially metastatic disease and multiple myeloma
Pain from tumour of infection tends to be described in what way?
- Worse at night
If there is any suspection of tumour or infection behind the cause of back pain which tests are required?
- Thorough history
- CRP, FBC, U&Es
- Bone biochemistry
- Plasma protein electrophoresis
- PSA for males
- Blood culture
- Bone scan
In patients with severe osteoporosis, which fractures may occur to the vertebral body?
Spontaneous crush fractures
Spontaneous crush fractures to the vertebral body as a result of osteoporosis can lead to what?
- Acute pain
What are the treatment options for osteoporotic crush fractures?
Balloon vertebroplasty (trial treatment, involving inserting balloon into vertebrae to bring cortices together and then injecting bone cement to recreate original bone structure)