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CSI year 2 > Case 9 backpain > Flashcards

Case 9 backpain Flashcards

1
Q
  • Where can back pain be felt generally?
A

Anywhere from the neck down to the hips in the spine

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2
Q
  • What are the 4 ways to relieve back pain?
A

Stay as active as possible and continue daily activities

Try exercises and stretches for back pain (walking, swimming, yoga and pilates)

Take anti-inflammatory painkillers (ibuprofen)

Use hot or cold compression packs for short term relief - you can buy these from a pharmacy, or a hot water bottle or a bag of frozen vegetables wrapped in a cloth or towel

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3
Q
  • When is it a good idea to get help for back pain?
A

If the pain does not start to improve within few weeks

If the pain stops you from doing day-to-day activities

If the pain is very severe or gets worse over time

You’re worries about the pain or struggling to cope

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4
Q
  • In what cases are surgery considered for back pain?
A

When it is caused by a specific medical condition

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5
Q
  • What treatment options may be given by a specialist?
A
  • group exercise classes- where you’re taught exercises to strengthen your muscles and improve your posture
  • manual therapytreatments, such as manipulating the spine and massage, which are usually done by a physiotherapist,[chiropractor]
  • psychological support,such ascognitive behavioural therapy , which can be a useful part of treatmentif you’re struggling to cope withpain

Radiofrequency denervation
seals off some of the nerves in your back so they stop sending pain signals (only for long-term lower back pain)

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6
Q
  • What 4 most common medical conditions typically cause back pain?
A

Slipped (prolapsed) disc where a disc of cartilage in the spine presses on a nearby nerve

Sciatica - irritation of the nerve that runs from the pelvis to the feet

  • ankylosing spondylitis- swelling of the joints in the spine, causes the small bones in your spine (vertebrae) to fuse.
  • spondylolisthesis- a bone in the spine slipping out of position
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7
Q
  • What additional symptoms do these back pain conditions tend to cause?
A

Numbness, weakness or a tingling sensation

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8
Q
  • How do you prevent back pain?
A
  • do regularback exercises and stretches
  • stay active
  • avoid sitting for long periods
  • take care when lifting
  • check your posture when sitting, using computers or tablets and watching television
  • ensure the mattress on your bed supports you properly
  • through a combination of ahealthy dietand regular exercise if you’re overweight– being overweight can increase your risk of developing back pain
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9
Q
  • When do you need to get immediate help for back pain?
A
  • numbness or tingling around your genitals or buttocks
    • difficulty peeing
    • loss of bladder or bowel control
    • chest pain
    • a high temperature
    • unintentional weight loss
    • a swelling or a deformity in your back
    • it does notimprove afterresting or is worse at night
    • it started after a serious accident, such as after a car accident
    • the pain is so bad you’re having problems sleeping
    • pain is made worse when sneezing, coughing or pooing
    • the pain is coming from the top of your back, between your shoulders, rather than your lower back
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10
Q
  • What type of pain passes through the reticular formation?
A

dull pain

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11
Q
  • What are the possible causes of Paul’s back pain?
A

Differentials for lower back pain:

Vertebra – compression fracture

Spinal cord – spinal cord compression

Nerve roots – radiculopathy

Lumbar muscles – lumbar muscular strain

Aorta – ruptured abdominal aortic aneurysm (AAA)

Kidneys – kidney stones

Pancreas – pancreatitis

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12
Q
  • What is the science of referred pain?
A

Because the nerves from different places come together in the spinal cord, the body may confuse the zone of where the pain comes from

Referred pain is pain perceived at a location other than the site of the painful stimulus/ origin

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13
Q
  • In radiculopathy is the pain usually on one or both sides?
  • What is radiculopathy?
A

One- unilateral

Range of symptoms produced by pinching a nerve root in the spinal column

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14
Q

What is mechanical pain

A

Caused by abnormal stress and strain on muscles of the vertebral column
Triggered by certain movements/ positions, comes and goes

the source of the pain may be in your spinal joints, discs, vertebrae, or soft tissues

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15
Q

causes of mechanical back pain

A

Common causes of mechanical back pain include spinal stenosis, herniated discs, zygapophysial joint pain, discogenic pain, vertebral fractures, sacroiliac joint pain, and myofascial pain.

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16
Q

Causes of radiculopathy

A

A common cause of radiculopathy is narrowing of the space where nerve roots exit the spine, which can be a result of stenosis, bone spurs, disc herniation or other conditions

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17
Q
  • Does cauda equina syndrome have unilateral or bilateral symptoms?
A

Bilateral

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18
Q
  • What is Cauda Equina syndrome
A

Cauda equina syndrome (CES) occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina.

compression to the spinal nerve roots inside the dura, beyond the termination of the spinal cord.

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19
Q
  • What are the symptoms of cauda equina syndrome?
A

Bilateral neurogenic sciatica

Reduced perineal sensation

Altered bladder function

Painless urinary retention

Loss of anal tone

Loss of sensory dysfunction

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20
Q
  • Most common compression sites in CES
A

L4/L5 and L5/S1

This is the area taking the largest load bearing effort

The less common causes are through infection or tumour

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21
Q
  • Onset of cauda equina syndrome
A

sudden onset

but gradual onset also possible

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22
Q
  • Why does compression of the nerves in the cauda equina cause difficulty initiating micturition?=
A

A compression of the S2-S4 nerve roots by an L4/L5 disc would mean there would be a loss of innervation

Parasympathetic control comes from the craniosacral region

Parasympathetic control promotes peeing (detrusor contraction and internal sphincter relaxation)

(sympathetic nerves that stop peeing are on L1-L3 level, so not compressed, so internal sphincter contraction and detrusor relaxation is still held)

23
Q
  • Serious conditions whose signs and symptoms may overlap with sciatica
A

Cauda equina syndrome

Spinal fracture

Cancer

Infection

24
Q
  • What are some of the red flag symptoms of Cauda Equina Syndrome?
A

Bilateral sciatica

Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle version or foot dorsiflexion

Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible

Urinary retention with overflow urinary incontinence

Loss of sensation of rectal fullness, if untreated this may lead to irreversible

Faecal incontinence

Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)

Erectile dysfunction

Pain radiating below the knees bilaterally

Laxity of the anal sphincter

Consider an assessment of anal tone but note that this does not need to be performed in primary care

25
Q

How does incomplete cauda equina syndrome progress?

what is complete cauda equina syndrome usually characterised by

A

incomplete cauda equina syndrome to complete cauda equina syndrome.

Complete cauda equina syndrome is typically characterised by painless urinary retention with overflow incontinence.

26
Q
  • What are some of the early warning signs for Cauda Equina Syndrome?
A

Loss of feelings/pins and needles between inner thighs or genitals

Numbness in or around your back passage or buttocks

Altered feeling when using toilet paper to wipe yourself

Increasing difficulty when you try to urinate

Increasing difficulty when you try to stop or control your flow of urine

Loss of sensation when you pass urine

Leaking urine or recent need to use pads

Not knowing when your bladder is either full or empty

Inability to stop a bowel movement or leaking

Loss of sensation when you pass a bowel motion

Change in ability to achieve an erection or ejaculate

Loss of sensation in genitals during sexual intercourse

27
Q
  • Should you make records at the same time as the events you are recording or as soon as possible afterwards?
  • Should you keep records that contain personal information about patients, colleagues or others securely and in line with any data protection law requirements?
A

Both

Yes

28
Q
  • What should clinical records include?
A

Relevant clinical findings

Decisions made and actions agreed and who is making the decisions and agreeing the actions

Information given to patients

Any drugs prescribed or other investigation or treatment

Who is making the record and when

29
Q
  • What can failure to quickly refer or treat a patient presenting with signs of CES lead to?
A

Paralysis, incontinence and impaired mobility

30
Q
  • How can a CES claim be successful?
A

Claimant has to show that the care provided by the doctor fell below the reasonable standard and there is a ‘breach of duty’

Claimant must then show that the breach has caused loss or damage which is termed ‘causation’

31
Q
  • Why can CES claims be expensive?
A

The degree of damage that resulted from the breach of duty will often be a fraction of the claim with the care costs and consequential losses forming the bulk of the overall value of the case

32
Q
  • What is the general progression of steps if a patient is suspected of CES?
A

Conduct a full examination to establish the likely cause of the back pain

If red flags are present, the patient needs to be seen in hospital urgently.

If no red flags are present, make a record in the notes to demonstrate you have considered the condition

If, after the assessment, the patient is being managed as having simple mechanical back pain. Advise the patient of the red flag symptoms and the importance of seeking urgent medical attention if these appear.

33
Q
  • What surgeons do in cauda equina
A

micro disectomy

remove disc material from vertebral canal, which is causing the compression

Continue to remove the fragments until finally, there is no further compression of the nerve sac in the canal

probe on the nerve sack to make sure nerve sac is loose and free

34
Q

what is Transduction

A

process in which a stimulus is converted into an action potential

35
Q
  • what do Chemoreceptors initiate an action potential in response to
A

cytokines that are generally released at the site of inflammation

this is why we feel pain at the site of inflammation

36
Q
  • what two types of fibre are in the spinothalamic tracts
A

one is taken by sharp pain-ad fibres

the other by dull pain-slower c fibres

myelination is different-different speed limit

37
Q
  • Pinprick happens explain
A

Pinprick—>neospinlothalamic tract—>synapses second neuron in the dorsal horn—→decussates then ascend straight to the thalamus where it synapses with a third neurone that leads the action potential to the respect of the somatic sensory cortex

It is also connect to the S2 region for visual integration and the insula, causing vasocontriction, sweating and increasing in pulse rase.

38
Q
  • dull pain due to inflammation
A

via the paleo spinothalamic tract, which synapses to a second neurone at the dorsal horn of the spinal cord.

This second neuron decussates, and it sends along the spinal cord where it reaches the reticular formation

then goes through the thalamus to reach the somatosensory cortex. The action potential is also take to the cingulate cortex, aversion, and amygdala, which initiates a sense of fear

39
Q
  • touch on wrist, explain process
A

First neuron, synapses with the medulla oblongata, decussate, synapses with a neuron to the thalamus, and then synapses with a third neuron, which is connected to the somatosensory cortex

40
Q
  • Affective neuroscience
A

the study of the neural mechanisms of emotion.

41
Q

What is Lumbago

A

(lower back pain) is the most common type

42
Q

4 causes of back pain (med ed)

A

Lumbar muscular strain/ sprain
Herniated nuclear pulposus
Spinal stenosis
Compression fracture

43
Q

uncommon causes of back pain (med ed)

A

Cauda equina syndrome
Spinal cord compression
Spondylolysis and/or spondylolisthesis
Vertebral discitis/osteomyelitis (infection)
Malignancy
Inflammatory spondyloarthropathy

44
Q

what are the three main concepts for the science of pain

A

Somatotopic arrangement- Different areas of the somatosensory cortex of the brain are associated with different areas of the body

Contralateral arrangement

Affective neuroscience- Some brain regions when stimulated by the right kind of signal, can initiate a physiological and a motivation output

45
Q

What is the dorsal column pathway responsible for

A

Fine touch (discriminative)
Proprioception
Vibration

46
Q

what is the spinothalamic tract responsible for

A

Crude touch (non-discriminative)
Pain
Temperature

47
Q

what are grey and white matter

A

The grey matter contains the cell bodies, dendrites and the axon terminals, where all synapses are. The white matter is made up of axons, which connect different parts of grey matter to each other.

48
Q

what does the cauda equina consist of

A

Cauda equina consists of spinal nerves L2-L5, S1-S5 and the coccygeal nerve

49
Q

why is CES pain bilateral

A

Central disc herniation → nucleus pulposus displaced from annulus fibrosus → compression onto spinal nerves within spinal canal → bilateral symptoms

50
Q

what is the sciatic nerve formed by

A

The sciatic nerve is formed by the combination of motor and sensory fibres fromspinal nerves L4 to S3.

51
Q

Why saddle paraesthesia?

A

Saddle sensation is around the buttocks and anus. It is supplied by theS3 to S5 nerve roots

52
Q

Why anal sphincter laxity and erectile dysfunction?

A

S2, 3, 4 innervates the anal sphincter, internal urethral sphincter and causes erection of the penis

53
Q

what is the most important investigation for CES suspect

A

InvestigationsThe most important investigation for cauda equina syndrome is anMRIspine
A CT myelogram may be considered situations whereby MRI is contraindicated

54
Q

when should you treat patients with CES for best chance of recovery

A

Treating patients within 48 hours after the onset of the syndrome provides a significant advantage in improving sensory and motor deficits as well as urinary and rectal function

CSI year 2 (8 decks)

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