Back pain flashcards
Jake Timothy
Consultant Spine surgeon and Neurosurgeon
Ganesh Baranihandaran
Consultant Pain Specialist
1
Sciatica
• -pain originating in the back and
radiating down posterior or lateral
thigh (sciatic nerve distribution)
-many causes such as piriformis synd,
lumbar spine probs
2
Radiculopathy
•
impairment of the nerve root leading to
neurologic problems
-paresthesia, numbness, change in Deep
Tendon Reflexes
3
Spondylosis
• Generic term for ‘wear and tear in the
spine’
• Used too much for normal physiological
ageing of the spine
4
Spondylolithesis
• Lithesis meaning ‘to slip’
• When anterior displacement of one
vertebra to another
• Can be diagnosed by x-ray
• If surgery is contemplated may need fusion
procedure as well as decompression
5
Strain or sprain
• Sprain affects the ligaments
• Strain affects the muscles
6
Anatomy of disc
•
-nucleus pulposus = gel center
-annulus fibrosus = surr + holds nuc pulp in
-degen disc dz = less water, inc compression of discs
with age
-nerve roots leaving = one below until C8 and then
becomes one above
ex = C5/C6 = C6 nerve root
ex = L5/S1 = L5 nerve root
ex = T1/T2 = T1 nerve root
7
History of low back
pain
•
-Onset
-Location
-Duration
-Character
-Ameliorating/Aggravating/Associated factors
-Radiation
-Timeline
-Severity
*OLD CARTS*
-ROS = to rule things out
8
Differential diagnosis
• *things to rule out first =
-cauda equina synd, fracture, OM,
infection, Cancer
*Others =
-herniated disc, scoliosis, SD,
ankylosing spondylitis, visceral dz
9
Red flags
•
1) Age > 50 = Fx, Cancer
2) Fever, recent infection = Infection
3) Significant trauma= Fx
4) Unrelenting night pain = Cancer, Fx
5) Progressive motor or sensory deficit = Cauda Equina, Cancer
6) Saddle Anesthesia= Cauda Equina
7) Difficulty urinating or fecal incontinence = Cauda Equina
8) Unexplained weight loss =Cancer
9) Hx or strong suspicion of cancer = Cancer
10) Hx of osteoporosis = Fx
11) Chronic oral steroids = Fx, Infection
12) IV drug use = Infection
10
Physical examination
•
-Gait and posture
-Palpation
-ROM
-Sensation = Light touch and Pin prick
-Strength
-Deep tendon reflexes
-Babinski (tells UMN deficit)
-Heel walking and toe walking = asses neuro and strength
*Special Tests
-Straight Leg Test - seated and lying
-FABER test
-Trendelenburg
11
Neuro exam
•
•
L1 Groin, iliopsoas, hip flexion
L2 anterior thigh, iliopsoas, sartorius, hip adductors-hip
flexion and adduction
•
L3 -Medial aspect of knee-Iliopsoas, quadriceps,
sartorius, hip adductors-Hip flexion, knee extension, hip
adduction
•
•
•
L4 = tibialis ant, patellar reflex, medial leg
L5 = ext hallucis longus, front of foot
S1 lateral leg, achilles reflex + eversion of foot
12
Lower motor neuron
deficit
•
-Weakness - flaccid paralysis
-DTR - decreased or absent
-Babinski -absent
-Atrophy - may be marked
-Fasciculations - may be present
**Typically spine probs affect LMNs
13
Upper motor neuron
deficit
• Weakness - Spastic paralysis
DTR - Increased
Babinski - Present
Atrophy - absent or due to disuse
Fasciculations - absent
14
Special tests
•
1) Straight leg test - done seated, lying, or
crossed (raise leg and see if use back to
help)
2) FABER = flexion, abudct, ext rotation;
testing hip + SI joint
3) Hoover's = try lift right, left will push down
15
Imaging options
•
*X ray = Boney architecture, fracture, osseous
lesions
*MRI = Soft tissue
*CT= Fracture, prior lumbar surgery
*Bone Scan = Cancer, osteomyelitis, stress fracture
*Myelography = dye into epidural space to see
compression; done only if CI to MRI
16
Cauda equina
•
*Reduction of volume of spinal canal
-Compression of nerve roots
-Muscle paralysis
-Urinary or Bowel dysfunction
*Causes = cancer, disc probs, hematoma
*Symptoms
-Radicular pain of both legs
-Saddle anesthesia (butt and back of legs)
-Difficulty voiding or loss of sphincter control
-Leg weakness
*Physical findings
-Sensory changes
-Difficulty standing
-Difficulty with heel or toe walking
*Tests
-MRI**, X ray, CRP, CBC, ESR
*Emergent surgical referral
17
Compression fracture
•
*High energy trauma
*Type of compression fracture
-Simple - anterior half of vertebral body
-Burst - extending into the posterior third of the vertebral body
-Posterior ligament disruption in flexion distraction injuries are
unstable
*Physical findings
-Tenderness to palpation over the vertebra
-Step off
-Hematoma
-Neuro exam
18
Acute low back pain
• LBP < 6 weeks in duration
*Causes
-strain or sprain
-twisting, repeated lifting, vibrating
equipment (common = bending down
and twisting)
19
Symptoms of low back
pain
•
*Symptoms
-LBP radiating into buttocks and posterior thighs
-R/O red flags
*Physical Exam
-No neurologic deficit
-Monitor flexion and extension
-With or without sciatica
20
Tests and treatment for
acute low back pain
• *Tests
-X ray not helpful
*Treatment
-Symptomatic Relief - including meds
-Return to activity - NO bed rest
21
Only evidence based
pharma treatments
• NSAID’s
• Paracetamol
• Avoid codeine based tables as cause
constipation and headaches
•
*Activity
-Lifting, Stretches, Physical Therapy
*Ice for 1st 24 hrs, then heat 20 min at a time
*Spinal manipulation (OMT, Chiropractic)
22
Degenerative disc/
chronic
•
*LBP > 3 months duration
*Recurrent and episodic symptoms
*Symptoms
-LBP radiating into the buttocks
-Aggravated by activities
-May have intermittent sciatica
*Physical Exam
-Lumbar or SI tenderness
-Muscle spasm
-Normal strength and neuro testing
-Negative straight leg test
-Deconditioning (no exercise makes it worse)
23
Cause of disc
herniation
• Lifting with twisting
Over time
Most commonly L4-5 (affects L5),
L5-S1 (affects S1) - b/c affects exiting
nerve root below not one that comes
out at that point
24
Symptoms of acute disc
•
*Symptoms
-Abrupt onset
-Pain worse in leg than back
-Radiating in dermatomal pattern = sciatica typ present
(but if have sciatica, not necessarily have disc
herniation)
-Pain worse with valsalva
-Worse with flexion!!
*Physical Exam
-May list when standing
-Straight leg test - positive if lean back
-Neurologic deficit - weakness, reflexes, sensory
25
Imaging of acute disc
• -If red flags present→
immediately
-After 4-6 week trial of conservative
care
-MRI, Myelography, CT
26
Treatment of acute disc
•
•
*Activity
-No bed rest
*Medications
-NSAIDs
-Muscle relaxants
-Gabapentin
-Opioids
*Physical Therapy
-Therapeutic ultrasound
-Transcutaneous electrical nerve stimulation (TENS)
-Traction
-Exercises
*Spinal manipulation = but NO HVLA
*Epidural spinal injections
*Surgery to relieve nerve root compression
27
Spinal stenosis
• Narrowing of the central spinal
canal by bone or soft tissue with
compression of nerve root
30% of those over 60
Most common at L2-3, L3-4, L4-5
28
Signs and symptoms of
LCS
•
*Symptoms
-Neurogenic claudication
-Pain relieved with flexing forward (worse with
extension!!)
-May have spondylolisthesis
*Physical Exam
-Pulses normal
-Reflexes may be decreased
-Proprioception impaired - positive romberg
-May have sensory changes
29
Treatment of spinal
stenosis
•
-NSAIDS
-Gabapentin
-Physical Activity
-Epidural Steroid injections
*Surgery
-Based on symptoms and other comorbidities
-Spinal fusion if also spondylolisthesis or scoliosis
30
•
Scoliosis
-Lateral curvature of the spine - named by convexity side
*Cause in adults
-Degenerative spondylosis
-Degenerative spondylolisthesis
*Symptoms
-Pain at region of deformity
-Radicular symptoms usually L4 or L5 nerve root
-Neuro symptoms less likely
-Getting shorter, "hump"
*Physical Exam
-Postural exam
-Palpate the spine
*Treatment
-NSAIDS
-Exercise program
-surgery if young
31
Spondylolithesis
•
*Anterior slippage of one vertebral body over the next
*Degenerative
-Degenerative of facet joints
-Intervertebral disc changes
-Lamina and pars interarticularis are intact
*Physical exam
-Loss of lordosis
-Step off of spinal processes
-Decreased reflexes
-Weakness in toe or heel walking
32
Imaging and treatment
•
*Imaging
-AP and lateral x ray
-Lateral will show slippage
*Treatment
-NSAIDS
-Exercise
-Weight loss
-Abdominal binder does not help!
-Surgery = fusion
33