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Head, Neck And Neuro > PBL- Back Pain Leading To Chronic Incapacity > Flashcards

PBL- Back Pain Leading To Chronic Incapacity Flashcards

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1
Q

What are the red flags of lower back pain?

A 
Previous history of malignancy 
Younger than 16, older than 50 with new pain
Weight loss
Prolonged steroid use
Recent serious illness
Recent significant infection
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2
Q

List some mechanical causes of lower back pain below.

A 
Trauma
Muscular and ligament pain
Pustular back pain
Facts joint syndrome
Lumbar disk prolapse 
Lumbar spondylosis
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3
Q

Describe the anatomy of an intervertebral disk.

A

Soft gelatinous centre called nucleus pulposus, encircled by a strong, ring-like collar of fibrocartilage called the annulus fibrosis.

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4
Q

What is the main function of an intervertebral disk?

A

Shock absorption

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5
Q

What happens in an intervertebral disk prolapse?

A

Nucleus pulposus is squeezed out of place and herniated through the annulus fibrosis

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6
Q

Name some reasons an IV disk would become damaged?

A

Trauma
Effects of aging
Degenerative disorders of the spine

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7
Q

Briefly describe pathology involved once an IV disk herniation has occurred?

A

Posterior protrusion of the nucleus pulposus towards the intervertebral foramen and its contained spinal root.
Annulus fibrosis becomes thin and poorly supported by posterior or anterior ligaments at this point

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8
Q

Which regions of the spine are most commonly involved in disk herniations?

A

Cervical and lumbar

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9
Q

Where are the signs and symptoms of a disk herniations seen?

A

Localised to the area of the body innervated by the affected spinal nerve roots- includes motor and sensory

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10
Q

If the nerve roots L4, L5, S1, S2 and S3 are damaged, what condition arises?

A

Sciatica

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11
Q

Describe where the pain is felt in sciatica?

A

Spreads down the back of the leg and over the sole of the foot

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12
Q

What are the most common sensory effects from spinal root compression?

A

Paraesthesia and numbness

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13
Q

What are the most common motor effects from spinal root compression?

A

Knee and ankle reflexes may be absent or diminished

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14
Q

What are the symptoms of severe spinal disease?

A 
Pain worse at rest
Thoracic pain
Fever
General malaise 
Urinary retention
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15
Q

What signs and symptoms of cord compression occur in severe spinal disease?

A 
Back pain
Leg weakness
Limb numbers
Ataxia
Urinary retention
Hyperreflexia 
Clonus
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16
Q

What signs and symptoms of cauda equina compression occur in severe spinal disease?

A 
Bilateral leg pain
Back pain
Urinary retention 
Perinatal sensory loss
Erectile dysfunction 
Reduced anal tone
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17
Q

What are the layers of protection for the spinal cord?

A 
Vertebrae
Vertebral ligaments
Fat and connective tissue in epidural space
Meninges
 CSF
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18
Q

At what point do the spinal nerves stop being covered in meninges?

A

Once they exit the spinal column through the intervertebral foramen

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19
Q

What is the epineurium?

A

The outer covering of spinal and cranial nerves

- continuous with dura mater

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20
Q

Describe the connective tissues of the dura mater.

A

Thick, strong, dense and irregular

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21
Q

Describe the connective tissues of the arachnoid mater.

A

Thin, avascular with loosely arranged collagen and elastic fibres

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22
Q

Describe the connective tissues of the pia mater.

A

Thin and transparent
Bundles of collagen fibres and some elastic fibres
- adheres to surface of spinal cord and brain

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23
Q

Which meningeal layer contain blood vessels? (At least in the spine :/)

A

Pia mater and dura mater

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24
Q

What are denticulate ligaments?

A

Triangular shaped membranous extensions of the pia mater than suspend the spinal cord in the middle of the rural sheath

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25
Where does the spinal cord arise and terminate in adults and babies?
Arises in the medulla oblongata Terminates - superior border of 2nd lumbar vertebrae in adults - L3,4 in newborns
26
What is the superior enlargement of the spinal cord, and where does it span?
It's a cervical enlargement, that nerves to and from the upper limb arise from Spans from C4 to T1
27
What is the inferior enlargement of the spinal cord, and where does it span?
It's a lumbar enlargement, that nerves to and from the lower limb arise from Spans from T9 to T12
28
What is the conical structure that is the end of the spinal cord called?
Conus medullaris (between L1, 2)
29
What is the film terminale?
Extension of pia mater that extends from conus medullaris to the arachnoid and dura mater at the coccyx - anchors spinal cord to coccyx
30
How many pairs of spinal nerves are there - and where do they all arise from?
31 pairs - 8 cervical - 12 thoracic - 5 lumbar - 5 sacral - 1 coccyx
31
What is contained in a dorsal root ganglion?
Cell bodies of sensory neurons
32
What is in the white matter of the spinal cord?
Bundles of myelinated axons of neurons
33
What are the anterior median fissure and posterior median sulcus of the spinal cord?
Anterior median fissure - wide groove on ventral side | Posterior median sulcus - narrow furrow on dorsal side
34
What is contained in the grey matter of the spinal cord?
Dendrites and cell bodies of neurons, unmyelinated axons and neuroglia
35
What is there grey commissure?
Crossbar between the two lateral sides of the grey matter
36
What is found in the centre of the grey commissure?
Central canal - contains CSF
37
What is the central canal continuous with in the medulla oblongata?
The fourth ventricle
38
What are nuclei?
Clusters of neuronal cell bodies arranged in functional groups in the grey matter
39
What parts of the spinal cord are the intermediate grey horns found in, and what do they contain?
Thoracic and upper lumbar | Contain autonomic motor nuclei - regulate activity of cardiac muscle, smooth muscle and glands
40
What is the difference between a nerve and a track?
Nerves are bundles of axons in PNS | Tracts are bundles of axons in the CNS
41
Describe A-alpha axons from the skin. | - size, speed, amount of myelin, sensory receptors
``` Largest nerve fibre (12.20micrometers) Fastest speed (80-120m/sec) due to thickest covering of myelin Carry Proprioception do skeletal muscle fibres ```
42
Describe A-beta axons from the skin. | - size, speed, amount of myelin, sensory receptors
Second largest after A-alpha (6-12micrometers) Second fastest after A-alpha (35-75m/sec) due to second thickest covering of myelin Carries mechanoreceptors of the skin fibres
43
Describe A-delta axons from the skin. | - size, speed, amount of myelin, sensory receptors
Second smallest nerve fibre (1-5micrometers) Second slowest nerve fibre (5-30m/sec) due to smallest covering of myelin Carriers pain and temperature fibres
44
Describe C-fibre axons from the skin. | - size, speed, amount of myelin, sensory receptors
The smallest nerve fibre (0.2-1.5micrometers) The slowest fibre (0.5-2m/sec) due to no myelin covering Carries temperature, pain and itch fibres
45
Which ganglia are pain receptor cell bodies for the face located in?
Trigeminal ganglia
46
When are nociceptors activated?
When the pain reaches a noxious threshold
47
Describe pain sensitisation in relation to nerve fibres?
Continued stimulation decreases the threshold at which nociceptors respond
48
What type of pain do the A-delta fibres send to the brain?
Localised, sharp 'first' pain | - responds to intense mechanical and thermal stimuli
49
What type of pain do the C-fibres send to the brain?
The poorly localised, diffuse 'second' pain (slow and burning) - polymodal; respond to mechanical, thermal and chemical stimuli
50
Name the three neurotransmitters used by nociceptive fibres.
Glutamate Substance P Calcitonin gene-related peptide (CGRP)
51
Nociceptive activation causes what to happen locally?
Neurotransmitter release centrally and peripherally | Redness, tenderness and swelling in the periphery
52
What are silent nociceptors?
Activated by peripheral neurotransmitters to expand to receptive field for painful stimuli
53
Activation of nociceptors leads to opening of cation channels (mainly sodium), which causes what?
Membrane depolarisation and generation of action potentials
54
How does a thermal stimuli activate A-delta and C-fibres?
Hot activates the TRPV1 receptor Cold activates the TRPM8 receptor Results in either cooling or warming of the body behaviours - mediated through projections to the hypothalamus
55
How does a mechanical stimuli activate A-delta and C-fibres
High threshold | Only activated when stimuli is noxious and may cause tissue damage
56
How does a chemical stimuli activate C-fibres?
Can be external irritation or substances released during tissue damage
57
What chemicals are released when tissues are injured?
Bradykinin 5-HT Prostaglandins Potassium ions
58
How are C-fibres activated in general?
In response to the chemicals procured by tissues during tissue damage - CGRP and substance P are released - mast cells are simulated - histamine release - vasodilation, plasma extravasion, oedema and bradykinin release
59
What happens to the activated threshold after the initial chemical release and vasodilation?
It is lowered to make the area more sensitive to pain - hyperalgesia - allondyia
60
Describe the shift of balance of inputs in the gate control theory of pain.
When hurt, an individual rubs the area that is sore to alleviate pain Balance of inputs shifts from C and A-delta fibres, and towards the mechanoreceptive A-beta fibres
61
Describe how shifting towards A-beta fires in the gate control theory works.
C and A-delta fibres activate projection neuron firing - causing pain These can be inhibited by inhibitory interneurons (that are inhibited by nociceptive input) A-beta firing is through the activate the inhibitory interneuron
62
How do endogenous opiods and opiates work?
Stimulates PAG matter in the midbrain, which sends descending, inhibitory pathways that supresses transmission of pain signals
63
Names the three classes of endogenous opioids.
Endorphins Enkephaline Dynorphin
64
Name three types of opioid receptor.
mu kappa delta
65
How is back pain managed between the ages of 5 and 20?
It's likely to be mechanical - managed with analgesia, brief rest and physiotherapy
66
What is the best way to manage back pain (in any age)?
Physiotherapy Being as active as possible Early management
67
Describe the role of the GP in management of back pain
Diagnostic triage Give accurate info Additional support for patients who don' return to work Referral
68
Describe the role of the pysiotherapist in management of back pain
Builds up muscles to cope with problems Prevents and manages musculoskeletal disorders/other health problems Works in hospital or community Passive modalities to assist pain relief - electric stimulation Provides pain relief
69
Describe the role of the osteopath in management of back pain
Instant pain relief Involves palpation, manipulation and massage Works with bone, muscles and connective tissues to diagnose and treat abnormalities Based in community and private sector
70
What is osteopathy?
A system of diagnosis and treatment based on the theory that may diseases are associated with disorders of the MSK system
71
What is chiropody?
Its based on the theory that all disorders can be traced to the incorrect alignment of bones, consequent malfunctioning of nerve and muscles
72
Describe the role of the chiropodist in management of back pain
Instant pain relief Involves manipulation - mainly of vertebrae Works with bone, muscles and connective tissues to diagnose and treat abnormalities Based in community and private sector
73
Describe the role of the hospital specialist in management of back pain
Further evaluates, manages and treats the underlying problem causing the back pain Cause may be mechanical, metabolic, malignant or infectious
74
What is a 'yellow flags', when regarding back pain?
Psycho-social barriers to recovery
75
List some yellow-flags of back pain.
``` Belief that pain is harmful and debilitating Fear - avoidance behaviours Sickness behaviours - extended rest Social withdrawal Emotional problems - constant low mood Problems at work Financial problems Overprotective family Inappropriate expectations of treatment ```

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