Back Pain, Red Flags & Spinal Deformity

Question 1

Back pain basics

Answer 1

Defined as chronic if >3 months

Neck – cervical pain/neck pain
Middle back – thoracic back pain
Lower back – lumbar back pain (Most Common)
Tailbone - coccydynia

Question 2

Back pain aetiology

Answer 2

1) Causes intrinsic to spine
a. Spinal MSK system
b. Neurological system (local)
c. Haematopoietic system

2) Causes extrinsic to spine
a. Extrinsic MSK system
b. Neighboring viscera
c. Neurological system (not local)

Question 3

Back pain differentials

Answer 3

Degenerative - Non-specific muscular sprain, disc disease, spinal stenosis

Vascular – aortic dissection (writhing in pain), spinal SAH

Neoplasm- severe unrelenting pain, nocturnal pain, unrelieved by bed rest

Infection – risk factors, fever, spinal tenderness (*more severe at rest)

Inflammatory – ankylosing spondylitis, RA etc. (*morning stiffness)

Trauma – nontraumatic pathological fracture, risk factors

Metabolic disorder: crystal deposition diseases: gout, pseudogout, hydroxyapatite, or calcium pyrophosphate dihydrate crystal deposition diseases

Neighbouring viscera – mediastinal or retroperitoneal disease aortic aneurysm, pancreatic/LN/urological disease

Question 4

Taking pain history

Answer 4

*ask for referred/radiated pain

Question 5

Back pain Red Flags

Answer 5

Neurological deficit
History of cancer
Systemic features – fever, chills, night sweats, weight loss
IV drug use
Immunosuppression
Trauma
Osteoporosis
Thoracic back pain
Pain at rest and at night
Age>50 yrs or <16 yrs

Question 6

What to do if red flag seen?

Answer 6

Neurological + MSK examination
Immobilisation if neoplasm, inflammation, infection suspected
Involve spine surgical services

Question 7

Lower Back Examination

Answer 7

Look Feel Move:
Look – deformity, curvature
Feel – spine, paraspinal musculature, SIJ
Move – flex, extend & lateral bend spine & hip
Tests – SLR, FABER (for hip joint pain)

Neurological exam:
Power, Sensation, Tone, Reflexes (L2-5, S1)

Vascular exam

Question 8

Neck pain differentials

Answer 8

Degeneration : cervical spondylosis, cervical radiculopathy, cervical myelopathy

Trauma: fracture, subluxation, sprain (including whiplash)

Infection: discitis, osteomyelitis, epidural abscess

Neoplasm: primary bone tumour, metastasis

Inflammation: rheumatoid arthritis, psoriatic arthritis

Vascular: Sub-arachnoid haemorrhage

Metabolic disorder: crystal deposition diseases: gout, pseudogout, hydroxyapatite, or calcium
pyrophosphate dihydrate crystal deposition diseases

Viscera - carotid dissection etc.

Question 9

Red flags for neck pain

Answer 9

Same as back pain
+ Headache, fever, neck pain & stiffness may be due to meningitis or SAH

Question 10

What to do under red flag emergency - fracture? and when to suspect?

Answer 10

Suspect non-traumatic fractures in patients with osteoporosis, elderly patients and patients on long term steroids.

Immobilise;
Assess upper limb & lower limb neurology, perineal sensation;
Assess further if UMN signs detected

Intervention:
XR or CT of spine region (CT preferred), Urgent MRI if has neurological deficit

Question 11

What is cauda equina syndrome, how does it present and what are the causes?

Answer 11

= Dysfunction of multiple lumbar & sacral nerve roots
*Presentations include urinary retention, urinary or faecal incontinence, saddle anaesthesia

Cause:
1. Compressive
cauda equina compression from large central herniated lumbar disc prolapse (Most Common)
tumour, etc.

2. Non-compressive
   polyradiculopathy, post RT, vascular, AS etc.

Question 12

What to do under red flag emergency - cauda equina syndrome?

Answer 12

Assess lower limb neurology, perineal sensation, anal tone and squeeze, bladder scan. Assess further if UMN signs detected

Intervention: Urgent MRI lumbar spine (including lower T spine), rest of spine if negative

Question 13

What is acute foot drop and what causes it?

Answer 13

= Weakness of ankle dorsiflexion

The most common cause of foot drop is peroneal nerve injury. Wide differentials incl peripheral neuropathy, UMN lesions etc

Question 14

What to do under red flag emergency - acute foot drop?

Answer 14

Assess: LL neurological exam. Check TP (inversion) – spared in Common Peroneal N lesion. Both DF & PF lost in “Flail foot”. L5 radiculopathy is painful.

Intervention: MRI Lumber spine to investigate L5 radiculopathy. EMG/NCS helpful >3weeks duration.

Question 15

How does acute cord compression present?

Answer 15

Rapid onset spinal pain
Severe weakness / numbness of extremities
+/- sphincter disturbance

Question 16

What to do under red flag emergency - acute cord compression?

Answer 16

Assess: A/B/C’s, temperature, neurological deficit esp level (C5-8, T1 = can be checked through upper limb; most thoracic ones can only be checked by sensation)

Intervention:
consider spinal immobilisation if suspected infection or cancer of spine
IVF if hypotensive
Dexamathasone for malignant spinal cord compression
Urgent MRI

Question 17

How does spinal osteomyelitis/epidural abscess usually present?

Answer 17

Focal back pain and low-grade fevers (although these may be absent in some patients, especially immunocompromised)

H/O recent spinal surgery or epidural catheter placement

H/O recent systemic infection

Question 18

What to do under red flag emergency - Spinal osteomyelitis +/- epidural abscess?

Answer 18

Assess:
A/B/C’s, temperature, neurological deficit, bloods

Intervention:
Consider spinal immobilisation, IVF if hypotensive, urgent MRI

Management:
Pathogen identification + culture & sensitivity
Decompression especially if deficit
Stabilisation if associated with instability/deformity

Dorsal SEA – laminectomy and drainage
Ventral SEA with discitis/osteomyelitis – drainage and stabilisation

Question 19

What is scoliosis?

Answer 19

Spinal deformity with sideways or coronal curve (over 10 degrees). Also has associated vertebral rotation

Question 20

What are patterns of scoliosis? How are they classified?

Answer 20

Patient may present with visible spinal deformity, pain, sideways listing, prominent rib hump, asymmetry of shoulders

Classified on basis of age:
Congenital
Juvenile (<10 yrs)
Adoloscent Idiopathic Scoliosis (MC) (10-18 yrs) –> usually associated with smth else if there is pain
Adult (adult onset)

Question 21

Causes of scoliosis

Answer 21

idiopathic, congenital, neuromuscular disease, spinal pathology, unequal leg length, degeneration, connective tissue disease, spinal tumour, spinal pain etc

Question 22

What are assessments/tests of scoliosis?

Answer 22

Assessment:
Detailed history, MSK spine exam and UL + LL neurological examination

Test : forward bending to look for rib hump (Adam’s test)

Refer to Spinal Deformity service –> Whole spine XR – AP & Lateral
May need MRI esp if atypical features or neurological exam abnormal

Question 23

What are potential treatments of scoliosis?

Answer 23

Management:
Based on skeletal maturity, severity of deformity and progression of deformity

Options:
Observation
Bracing - for milder growing patients
Operation

Question 24

What is kyphosis?

Answer 24

Spinal deformity with excessive convex curvature of the spine, commonly involving the thoracic spine

This is a sagittal deformity - seen upon inspecting patient from the side. Unlike scoliosis, which is a coronal deformity (seen upon inspecting patient from the back)

Thoracic spine is naturally kyphosed. Kyphosis means hyper-kyphosis – excessive kyphosis

Question 25

Cause, assessment, management for kyphosis

Answer 25

Causes: Scheuermanns disease, osteoporosis with wedge fractures Asessment: Similar to scoliosis Management: Majority are managed conservatively. Operative treatment for severe kyphosis

Question 26

Describe spondylolisthesis

Answer 26

Anterior subluxation of one vertebra on another. Most Common L5/S1. Another sagittal spinal deformity

Question 27

Aetiology of spondylolisthesis

Answer 27

Type 1: dysplastic – congenital. Spina bifida occulta Type 2: isthmic – defect in pars, seen at L5S1 Type 3: degenerative, seen at L4L5 Type 4: traumatic – injuries other than pars fracture Type 5: pathologic – bone disease

Question 28

How to assess severity of spondylolisthess?

Answer 28

Meyerding grading Spondylolisthesis % = listhesis/AP dimention of VB above % Grade I less than 25% Grade II 25 - 50% Grade III 50 – 75% Grade IV 75 – 100% Spondyloptosis >100%

Question 29

Management for spondylolisthesis

Answer 29

Management: Isthmic Significant leg symptoms : Decompression with fusion preferred Degenerative Significant leg symptoms : Grade I & II with no instability on standing X-rays – Decompression only. Adverse features seen – Decompression with fusion. For both fusion could be instrumented or non-instrumented. Postero-lateral or inter-body

Question 30

What is cervical radiculopathy and how does it present?

Answer 30

= Dysfunction of cervical nerve root Pain radiating from neck down into the arm; Numbness and/or weakness in the upper extremity

Question 31

Causes for cervical radiculopathy + differentials from the presented symptoms

Answer 31

Causes: Cervical disc prolapse Vertebral osteophytes Other compressive lesions like tumours Differential diagnosis: Shoulder joint disease, peripheral nerve compression, cervical facet joint syndrome. Referred pain - angina

Question 32

Types of cervical radiculopathy

Answer 32

1. C5 from C4/5 disc. Rare. Pain radiates to shoulder. Biceps reflex 2. C6 from C5/6 disc. 20%. Pain radiates to thumb, lateral forearm. Brachioradialis reflex 3. C7 from C6/7 disc. 70%. Pain radiates to fingers 2&3. Triceps reflex 4. C8 fom C7T1 disc. 10%. Pain radiates to fingers 4&5. Finger reflex

Question 33

Investigations + Management of cervical radiculopathy

Answer 33

Investigation: MRI, CT myelogram ( if MRI contraindicated) Management: 1. Conservative : analgesics & physiotherapy. 90% improve 2. Surgery: for arm pain refractory to conservative management, progressive neurological deficit. Options: anterior cervical discectomy & fusion (ACDF) anterior cervical discectomy & disc replacement (ACDR) posterior cervical foraminotomy

Question 34

What is cervical myelopathy and what are the presentations?

Answer 34

= Dysfunction of cervical spinal cord History of slow progressive symptoms; Clumsiness of hands and feet, mild gait disturbance, paraesthesia of upper and lower extremities; Later symptoms of loss of coordination, changes in gait and stiffness, change in bowel or bladder function

Question 35

What are the causes of cervical myelopathy and how is the disease classified?

Answer 35

Causes: 1. Disc osteophyte complex 2. Ligamentous hypertrophy 3. Degenerative spondylolisthesis 4. Other compressive lesions – tumours, pannus, canal stenosis Classification Ranawat I – Pain, no deficit II – subjective numbness/weakness, hyper-reflexia III – objective weakness, IIIA is ambulant, IIIB is non-ambulant Nurick Japanese Orthopaedic Association score Upper limb motor Lower limb motor Sensory symptoms Bladder symptoms

Question 36

Differentials, investigations and management of cervical myelopathy

Answer 36

Differential diagnosis: subacute combined degeneration of the spinal cord (SACD), MND, MS Investigation: MRI, CT myelogram ( if MR contraindicated) Management: 1. Surgery: anterior vs posterior approaches to decompressing the spinal cord Anterior cervical discectomy/corpectomy & fusion Cervical laminectomy +/- instrumented fusion, Cervical laminoplasty 2. Conservative: suitable only for patients with mild symptoms (mJOA<12)

Question 37

What kind of structural degeneration can happen with degenerative disc disease?

Answer 37

1. Disc – disc desiccation, annular tears, disc bulge, disc prolapse, disc fibrosis and resorption 2. Facet joint – hypertrophy, effusions and laxity 3. Ligamentum flavum hypertrophy

Question 38

What is lumber disc herniation?

Answer 38

When internal nucleus of the disc starts protruding and putting pressure on outer ring of the disc

Question 39

What can lumbar disc herniation cause and what is the management?

Answer 39

Can cause: 1. Lumbar radiculopathy – “Dysfunction of lumbar nerve root” : Pain radiating into the leg; numbness and/or weakness in the nerve root distribution. Pain is constant, worse with WB, Valsalva & SLR 2. Cauda equina syndrome – “Dysfunction of multiple lumbar & sacral nerve roots” : typical features include urinary retention, urinary or faecal incontinence, saddle anaesthesia. Lumbar radiculopathy features are also seen in most patients Management: Lumbar radiculopathy is managed conservatively initially. Most improve. Surgery – lumbar discectomy

Question 40

What are associated pathologies in lumber stenosis and what are the types of the disease?

Answer 40

Facet & ligament hypertrophy, additional spondylolisthesis in some 1. Central stenosis – compression of all the nerve roots passing through 2. Lateral recess stenosis – compression of the transiting nerve root 3. Foraminal stenosis – compression of the exiting nerve root

Question 41

How does lumbar stenosis present and what are some other differentials for the presentation?

Answer 41

Stenosis tends to present with claudicant leg pain worse with walking/prolonged standing and relieved upon flexion of spine. Can also present with radiculopathy Differentials: Vascular claudication, hip OA, facetogenic pain, spinal tumour, SIJ OA

Question 42

Investigation & Management for lumbar stenosis

Answer 42

Investigation: MRI, CT +/- myelogram if MRI contraindicated Management: 1. Conservative: 3/5 stable, 1/5 improve, 1/5 worse 2. Surgical options Lumbar laminectomy – for central stenosis Lumbar laminectomy with fusion – option for central stenosis and slip>grade II Lumbar laminotomy (decompression) – for isolated lateral recess stenosis Direct / Indirect foraminal decompression via I/B cage – for isolated foraminal stenosis Limitation of extension via interspinous distraction device – MIS option for central stenosis in frail patients