Back Pain and Problems

Question 1

What may be some suspicious features, or red flags, of back pain?

Answer 1

1. Systemic upset - Fevers, night sweats, weight loss, fatigue and malaise
2. New back pain in the elderly (>60)
3. Back pain in the young (<20)
4. Pain which is constant, severe or worse at night
5. Saddle anaesthesia
6. Bladder/bowel upset
7. History of cancer (any)
8. ​History of steroids

Question 2

What is saddle anaesthesia?

Answer 2

Loss of sensation restricted to the area of the buttocks, perineum and the inner thighs

Question 3

What does testing the L1/2 myotome involve?

Answer 3

Hip flexion

Question 4

What does testing the L3/4 myotome involve?

Answer 4

Knee extension

Question 5

What does testing the L5 myotome involve?

Answer 5

Foot dorsiflexion

Question 6

What does testing the S1/2 myotome involve?

Answer 6

Ankle plantarflexion

(It can often be hard to pick up weakness here, a good way to test is to ask the patient to go on their tip toes)

Question 7

What is the gold standard investigation for back pain?

Answer 7

MRI

Question 8

What is the problem with using MRI for back pain?

Answer 8

It can result in many false positives

Abnormalities are common, but they often don’t cause any problems

Question 9

What is a diagnostic facet injection?

Answer 9

An injection of steroids in the facet joint to test if there is improvement

Question 10

On MRI, what is the appearance of disc inflammation?

Answer 10

Hamburger appearance

Question 11

What is sciatica?

Answer 11

Buttock and/or leg pain in a specific dermatomal distribution coupled with neurological disturbance of the L4, L5 or S1 nerve roots

Pain radiates to the sensory aspect of the sciatic nerve

Question 12

When surgery is undertaken for a prolapsed disc, what is the aim of the surgery?

Answer 12

To reduce leg pain

Question 13

Why will surgery only be considered after 3 months of no improvement for a prolapsed disc?

Answer 13

1. There is no long term benefit so rushing into surgery is pointless
2. The patient must get back to work as their life will be impacted after 3 months
3. There are risks to surgery so it should not be rushed into
4. Most (70%) cases settle by themselves within 3 months

Question 14

What is the first line management of a prolapsed disc and associated back pain?

Answer 14

• Short bed rest - only when really required
• Anti-inflammatories +/- muscle relaxant (diazepam)
• Early mobilisation (potentially with physio)
• Return to normal activity
• Education

Question 15

What is the second line management of back pain associated with a prolapsed disc?

Answer 15

• Physiotherapy
• Osteopathy/chiropractor
• TENS/psychologist/pain clinic
• Complementary therapies
• Surgery (rare)

Question 16

Why is cauda equina syndrome an emergency?

Answer 16

There may be limited time (<48 hours) to treat

Question 17

How must spinal fractures be dealt with initially?

Answer 17

• Immobilise
• X-ray
• Deal with other injuries

Question 18

How can secondary spinal cord damage occur?

Answer 18

• Swelling
• Oedema
• Ischaemia
• Thrombosis of small vessels
• Venous obstruction

Question 19

What are the 2 main patterns of spinal cord injury?

Answer 19

1. Complete
2. Incomplete

Question 20

What are the three main types of incomplete spinal cord injury?

Answer 20

1. Brown-Sequard
2. Central cord injury
3. Anterior cord injury

Question 21

How does a central spinal cord injury typically occur?

Answer 21

Forced hyperextension

Question 22

Anterior cord injuries are usually seen after what?

Answer 22

Vascular insult

Question 23

What are the worst problems that cause secondary damage to a spinal cord?

Answer 23

1. Hypoxaemia
2. Hypotension

Also:

• Stretching
• Compression
• Undue movement
• Inappropriate surgery
• Infection

Question 24

How should ankylosing spondylitis be initially managed?

Answer 24

• Immobilise in natural position (no collars)
• Mandatory CT

Question 25

What are the 4 types of scoliosis?

Answer 25

1. Congenital 2. Early onset 3. Late onset 4. Sencondary

Question 26

What is Heuter-Volkmann's law?

Answer 26

Increased pressure across an epiphyseal growth plate inhibits growth

Question 27

Secondary scoliosis can result from what?

Answer 27

* Neuromuscular problems * Tumours * Cerebral-palsy * Spina bifida

Question 28

What is spondylolysis?

Answer 28

Defect in the pars interarticularis of vertebrae

Question 29

What is spondylolisthesis?

Answer 29

Forward slippage of one vertebrae onto another

Question 30

What is mechanical back pain?

Answer 30

Recurrent relapsing and remitting back pain with no neurological symptoms

Question 31

What are causes of mechanical back pain?

Answer 31

1. Obesity 2. Poor posture 3. Poor lifting technique 4. Lack of physical activity 5. Depression 6. Degenerative disc prolapse 7. Factet joint OA 8. Spondylosis

Question 32

What is spondylosis?

Answer 32

Intervertebral discs lose water content with age which causes less cushioning and secondary OA due to increased facet joint pressure

Question 33

What is the main treatment for mechanical back pain?

Answer 33

Analgesia Physiotherapy

Question 34

When would spinal stabilisation surgery be indicated for mechanical back pain?

Answer 34

1. A single level is affected by OA or instability 2. The pain has not improved despite physio and conservative management 3. There are no secondary gains from surgery e.g. compensation claim

Question 35

When does an acute tear in the out annulus fibrosis typically occur?

Answer 35

Heavy lifting

Question 36

When there is a tear in the annulus fibrosis of a intervertebral disc, when is the pain characteristically worse?

Answer 36

When coughing

Question 37

Why is pain severe with acute disc tear?

Answer 37

The periphery of the disc is richly innervated

Question 38

What are the mainstay of treatment for acute disc tear?

Answer 38

Analgesia and physiotherapy

Question 39

The nucleous pulposus may herniate through a tear in the annulus fibrosis which can impinge on nerve roots causing what?

Answer 39

1. Pain in a dermatomal distribution 2. Reduced power in a myotomal distribution

Question 40

Where are the most common sites for disc heriation/prolapse to occur?

Answer 40

L4, L5 and S1 nerve roots

Question 41

How can the radicular pain in disc prolapse be described?

Answer 41

Neuralgic burning or severe tingling pain whichradiates to the back of the thigh to below the knee

Question 42

An L3/4 disc prolapse leads to __ root entrapment which causes pain down to the _________ \_\_\_\_\_\_\_\_\_, loss of power to which muscles and a reduction in which reflex?

Answer 42

L4 Medial ankle Quadriceps Knee jerk

Question 43

An L4/5 disc prolapse leads to __ root entrapment which causes pain down to pain down the _________ of the foot and loss of power to which muscles?

Answer 43

L5 Dorsum Extensor hallucis longus and tibialis anterior

Question 44

An L5/S1 disc prolapse leads to __ root entrapment which causes pain down to the _________ of the foot, loss of power _________ and a reduction in which reflex?

Answer 44

S1 Sole Plantarflexion

Question 45

What are the treatment options for sciatia?

Answer 45

1. Analgesia 2. Maintaining mobility 3. Physiotherapy 4. Drugs for neuropathic pain (gabapentin, pregabalin, amitriptyline) 5. Surgery (for very few cases)

Question 46

Why does OA sometimes lead to sciatica?

Answer 46

Osteophyte formation can result in osteophytes impinging on nerve roots causing sciatica

Question 47

What is the treatment for OA induced sciatica?

Answer 47

Surgical decompression with trimming of impinging osteophytes

Question 48

What is spinal stenosis?

Answer 48

Narrowing of the spinal canal due to a bulging ligamentum flavum, osteophytes, bulging discs atc

Question 49

Which age of patient is most likely to suffer from spinal stenosis and what is the classic complaint?

Answer 49

60 Pain in legs when walking (claudication)

Question 50

How is claudication induced by spinal stenosis different from claudication induced from PVD?

Answer 50

1. The claudication distance is inconsistent 2. The pain is burning rather than cramping 3. Pain is less when walking uphill as this creates more space in the spinal canal 4. Pedal pulses are preserved (dorsalis pedia, tibialis posterior)

Question 51

When may surgery be indicated for spinal stenosis?

Answer 51

1. When conservative management fails e.g. weight loss, physiotherapy, analgesia 2. There is MRI evidence of stenosis

Question 52

What causes cauda equina syndrome?

Answer 52

A very large central disc prolapse which compresses all the nerve roots of the cauda equina

Question 53

Why is cauda equina syndrome an emergency?

Answer 53

The affected root control urination and defaecation Prolonged compression can cause permanent nerve damage

Question 54

What are the classic signs of cauda equina syndrome?

Answer 54

1. Bilateral leg pain 2. saddle anaesthesia 3. Urinary retention is more common than incontinence 4. Faecal incontinence/constipation

Question 55

Which tests are essential in a patient with suspected cauda equina syndrome?

Answer 55

1. Rectal examination (PR) 2. MRI (determines level of prolapse)

Question 56

New back pain in people over 60 is considered a red flag, why is this?

Answer 56

Older people are at higher risk of neoplasia, especially metastatic disease and multiple myeloma

Question 57

Pain from tumour of infection tends to be described in what way?

Answer 57

1. Contant 2. Unremitting 3. Severe 4. Worse at night

Question 58

If there is any suspection of tumour or infection behind the cause of back pain which tests are required?

Answer 58

1. Thorough history 2. CRP, FBC, U&Es 3. Bone biochemistry 4. Plasma protein electrophoresis 5. PSA for males 6. Blood culture 7. CXR 8. Bone scan 9. MRI

Question 59

In patients with severe osteoporosis, which fractures may occur to the vertebral body?

Answer 59

Spontaneous crush fractures

Question 60

Spontaneous crush fractures to the vertebral body as a result of osteoporosis can lead to what?

Answer 60

1. Acute pain 2. Kyphosis

Question 61

What are the treatment options for osteoporotic crush fractures?

Answer 61

Conservative Balloon vertebroplasty (trial treatment, involving inserting balloon into vertebrae to bring cortices together and then injecting bone cement to recreate original bone structure)