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Flashcards in Seminar H - Back Pain Deck (59)
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Common Conditions 0-15

Osteochondritis, Scoliosis


Common Conditions 15-30

Prolapsed intervertebral disc
Ankylosing spondylitis


Common Conditions 30-50

Prolapsed intervertebral disc
Carcinoma (lung, breast, prostate, thyroid and kidney)
Degenerative disease


Common Conditions 50 yrs +

Paget’s disease


Spondylosis → Definitions

Intervertebral dis generation, instability osteoarthritis (OA) of the facets joints within any part of the spine but more commonly the cervical and lumbar regions.
Cervical region → cervical spondylosis


Spondylosis → Intervertebral dis generation is a

Normal, active, age related process involving both genetic, biomechanical and environmental factors which cause disruption of the chemical constituents of the cartilaginous annulus fibrosis and inner gel like nucleus pulposus


Spondylosis → Resulting process

Micro tears in the AF, escape of the NP a decreased disc space, reduced shock absorption and flexibility.
The vertebra and the synovial joints then develop compensatory degenerative changes typical of the changes of osteoarthritis namely osteophytes, loss of joint space, subchondral sclerosis and subchondral cysts3.


Spondylosis → Presentation

Chronic and intermittent back pain typically following physical activity, which is progressive and is often associated with acute exacerbations and diminished spinal mobility, stiffness and muscles spaces.


Spondylosis → Sondylosis knock on effects leading to

Simple Low Back Pain
Nerve root compressions

→ Intervetebral disc prolapse
Development of spinal stenosis


Neurological features of nerve root irritiaion results because

Impingement by the prolapses disc, inflamed synovial joints of degenreat efacet joints and the osteophytes that result from the osteoarthritis of the facet joint degeneration


Xray presentaion

1. Disc space narrowing
2. Sclerosis
3. Deformity
4. Marginal osteophytes



Simple analgesics
Corsets for support
Surgery (Severe cases – spinal fusions and spinal decompression)


Simple Low Back Pain → implies no nerve root irritation or serious spinal injury.
Characterised by

1. Onset 20-55 yrs
2. Presence of lumbrosacral, buttock and thing pain
3. Mechanical in nature, varying with physical activity anf with time
4. Patient is otherwise well with no systemic features
5. Clinical features resolve within six weeks
6. Pain may persist or relapse over time


Simple Low Back Pain → implies no nerve root irritation or serious spinal injury.Xray (not usually needed) may show

Simple degenerate change or OA


Osteoarthritis X-Ray features →

1. Traction spurs
2. Spondyliolisthesis
3. Disc space narrowing


Facet joint OA that is characterised by →

1. Joint space narrowing
2. Subchondral sclerosis
3. Osteophytes
4. Subchondral cysts
5. Root canal stenosis


Nerve Root Pain Presents with usually

with leg pain rather than back pain. It is often helpful to ask the % of back pain versus leg pain when eliciting the symptoms from the patient. The pain is often in a nerve root distribution.


Nerve Root Pain Symptoms characterised by

• Unilateral leg pain which is worse than low back pain.
• Pain which radiates to the calf foot or toes.
• Numbness and paraesthesia present in the same direction.
• Clinical signs of nerve root irritation
• Straight leg raise reproduces leg pain below knee
• Bow String sign
• Lasegue's sign
• Cross leg pain
• Localised neurological signs Power/Reflexes/Sensory loss


Serious Spinal Pathology → characterized by

• Onset in individuals who are aged less than 20 or greater than 55 years.
• Constant, progressive, unrelenting, non-mechanical pain.
• Thoracic pain.
• A past medical history of carcinoma.
• Drug misuse, steroid therapy, HIV.
• Violent trauma in the young e.g. an RTA . Trauma in the elderly osteoporosis.
• Constitutional features - fever, fatigue, malaise and weight loss.
• The presence of neurological features.
• Structural deformity.
• Severe persistent restriction of lumbar flexion.


Intervertebral Disc Prolapse →Definition

Very simply, each intervertebral disc, which is located between each vertebra, is composed of an outer ring of cartilaginous annulus fibrosis (red arrow) and an inner centre of gelatinous nucleus pulposus (green Arrow).

When an intervertebral disc prolapses, as has occurred in the adjacent diagram, the central nucleus pulposus is forced or extruded posterolaterally causing the annulus fibrosis to bulge, a complete prolapse occurs when the nucleus pulposus extends beyond the annulus fibrosis.


Intervertebral Disc Prolapse → Clinical features produced when

Extrusion impinges on the spinal nerve roots and spinal cord.

Severity and pattern of the symptoms and signs depend on the site of the prolapsed intervertebral disc.


Intervertebral Disc Prolapse →Note:

No correlation between the size of prolapse and the symptoms which appear to be related to the amount of inflammation involving the dorsal root ganglion of the compromised nerve root


Intervertebral Disc Prolapse → Clinical features

• A sudden or insidious onset of severe low back pain
• Muscle spasm
• Localised tenderness
• Diminished lumbar spinal movements A visible scoliosis.


Intervertebral Disc Prolapse → Clinical features typically occur during

• An episode of coughing
• Lifting
• Sneezing
• Twisting in which there is a recent history of trauma, back strain or injury.


Intervertebral Disc Prolapse → If there is nerve root involvement

• Severe unilateral shooting pains will radiate to buttocks, thigh or calf
• In association with paraesthesia
• Numbness
• Other neurological signs


Osteomyelitis Definition

As an infection of bone, but more specifically vertebral osteomyelitis, when the vertebral bodies become infected, can occur.


Osteomyelitis Common infecting organism in the UK is

Staphylococcus aureus followed by E. coli, Pseudomonas and Proteus.


Osteomyelitis Routes of bacterial spread

Direct or haematogenous (via the venous plexus of Batson).


Osteomyelitis Method of diagnosis



Osteomyelitis Pathologically

Is an infection with a subsequent inflammatory response, abscess formation (like the tuberculous "Potts abscess"), ischaemia and hence bone death (sequestrum). New bone can also occur (involucrum) as can the development of sinuses (cloacae) in severe disease which then discharge pus.

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