Baker and Burns Flashcards
Relationship between segmental nerve root, spinal nerves, vertebral column, intervertebral foraminae in health and acute disc herniation
nerves leave through the intervertebral foramina
• Once outside the vertebral column, the spinal nerves divide into branches.
o The dorsal ramus: Contains nerves that serve the dorsal portions of the trunk carrying visceral motor, somatic motor, and sensory information to and from the skin and muscles of the back.
o The ventral ramus: Contains nerves that serve the remaining ventral parts of the trunk and the upper and lower limbs carrying visceral motor, somatic motor, and sensory information to and from the ventrolateral body surface, structures in the body wall, and the limbs
what is a laminectomy
removal of all or part of the vertebral bone (lamina)
what is the bolam test
If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”.
what is the bolitho ammendment
An addition to the Bolam test of the legal standard of care required in negligence actions, which states that a professional’s acts or omissions be assessed to see if (i) they accord with a reasonable body of opinion and (ii) they withstand the logical analysis of the court.
what was the Montgomery ruling
patient’s should be given all the necessary info in order to gain valid consent, even if the doctor feels the risk is small.
clinical features of cauda equina
- Bilateral neurological deficit of the legs e.g. major motor weakness with knee extension, ankle eversion, or dorsiflexion
- Recent onset urinary retention and/or urinary incontinence
- Recent onset faecal incontinence
- Saddle anaesthesia or paraesthesia
- Unexpected laxity of anal sphincter
Ddx for cauda equina
- Conus medullaris syndrome
- Mechanical back pain or prolapsed lumbar disc
- Fracture
- Spinal tumour
- Spinal cord compression
- Peripheral neuropathy
- Guillian barre
- HIV related myelopathy
- Myotrophic atherosclerosis
- MS
- Diabetic neuropathy
- Hereditary muscular dystrophy
describe the curvature of the spine
Cervical- lordosis
Thoraic- kyphosis
Lumbar- lordosis
Sacral- kyphosis
red flags for back pain
TUNAFISH
Trauma Unexplained weight loss Neurologic symptoms Age >50 Fever IVDU Steroid use Hx of cancer
Yellow flags for back pain
- Pain is harmful or severely disabling
- Fear-avoidance behaviour
- Sickness behaviours
- Low mood
- Social withdrawal
- Expectation that passive treatment rather than active participation will help
Criteria for referral of back pain
- they have neurological features of cauda equina syndrome (sphincter disturbance, progressive motor weakness, saddle anaesthesia, or evidence of bilateral nerve root involvement)
- serious spinal pathology is suspected
- they develop progressive neurological deficit (weakness, anaesthesia)
- they have nerve root pain that is not resolving after 6 weeks
- an underlying inflammatory disorder such as ankylosing spondylitis is suspected
MICA naproxen
- MOA: NSAID- blocks COX1 and COX2 enzymes resulting in decreased PG synthesis. COX2 produces PGs that mediate pain, fever and inflammation- the effects of Naproxen on this enzyme are therapeutic, but its effects on the COX1 enzyme result in the side effects.
- Indications: pain and inflammation in rheumatic disease, MSK disorders, dysmenorrhoea, acute gout, acute migraine
- Cautions: allergic disorders, cardiac impairment, cerebrovascular disease, coagulation defects, connective tissue disorders, dehydration, elderly , heart failure, hx of GI disorders, ischaemic heart disease, peripheral arterial disease, uncontrolled HT
- CI: adverse GI bleeding, active GI ulceration, hx of GI bleeding related to previous NSAID use, history of GI perforation related to previous NSAID use, hx of recurrent GI haemorrhage, hx of recurrent GI ulceration, severe heart failure. Avoid in the third trimester- risk of closure of foetal ductus arteriosus in utero and pulmonary HT of the newborn. May also delay onset of labour and prolong the duration of labour.
- Adverse effects: agranulocytosis, alopecia, angioedema, asthma, cognitive impairment, impaired concentration, confusion, constipation, depression, diarrhoea, dizziness, drowsiness, dyspnoea, fatigue, GI discomfort, glomerulonephritis, haemorrhage, headache, hyperkalaemia, infertility in female
MICA omeprazole
- MOA: proton pump inhibitor- inhibits H+/K+ ATPase in the gastric parietal cells, which prevents gastric acid secretion.
- Indications: H. pylori eradication, benign gastric ulceration, duodenal ulceration, prevention of gastric ulcer relapse, prevention of duodenal ulcer relapse, prophylaxis of ulcers in NSAID use, Zollinger-Ellison syndrome, GORD, severe oesophagitis, acid reflux disease, functional dyspepsia.
- Cautions: can increase risk of fractures, may increase risk of GI infections e.g. C. diff, may mask the symptoms of gastric cancer in adults, all patients at risk of osteoporosis.
- CI: ???
- Adverse effects: abdominal pain, constipation, diarrhoea, dizziness, dry mouth, GI disorders, headache, insomnia, nausea, skin reactions, vomiting, bone fractures, confusion, depression, drowsiness, leucopenia, malaise, myalgia, paraesthesia, peripheral oedema, thrombocytopenia, vertigo, vision disorders.
3 types of back pain
mechanical, inflammatory, neurological
symptoms of mechanical back pain
• Mostly lower back
• May radiate to buttocks and thighs
• May get spasms
• More noticeable with flexion and when lifting heavy objects
• Worsened when sitting or standing
• Eased by lying down and walking
• Disruption to muscles, spine, intervertebral disk or nerve outlets
• Can occur at any age- most common in 20-55’s
• Called simple back pain
• More acute onset in comparison to inflammatory
• Precipitating factors
o Twisting, bending of lifting
• Usually affects lumbar spine- confined to L2-4
• Nature of pain: dull ache, constant
• Usually goes within 6 weeks
• Advice for patients: will improve over time (weeks to months), NSAIDs, heat, ice, rest, physiotherapy
