1. Spinal pain

2. Case 1 Mr John Brown is 52 years of age He develops acute severe back pain after digging a tree out of his garden Two days later he has pain in his left leg from hip to foot He develops numbness in his left foot

3. Case 1 – some questions What are the main parts of the spine? At each level is the spine the same? What is the relationship between the spine and the nerves? Which structures might cause pain? What do we mean by red flag symptoms?

4. Simple back pain Back pain is the largest single cause of lost working hours amongst both manual and sedentary workers; in the former, such as miners, dockers and nurses, it is an important cause of disability. Although most people get back pain, and although there are a large number of possible causes, a precise diagnosis is made in only a few cases. peak prevalence of back pain is in those aged 45-59 years little difference in the prevalence in men and women. work related back pain is more common among males. 90% of acute episodes of low back pain will resolve within 6 weeks. A clinical classification of some of the causes of back pain is given below: mechanical inflammatory neurological sinister referred unclassified

5. Red flag for serious spinal pathology Presentation less than age 20 or onset over age 55 years Violent Trauma: eg fall from a height, RTA Constant, progressive, non-mechanical pain Thoracic pain PMH - Carcinoma Systemic steroids Drug abuse, HIV Systemically unwell Weight loss Persisting severe restriction of lumbar flexion Cauda equina syndrome/widespread neurological disorder – Difficulty with micturition – Loss of anal sphincter tone or faecal incontinence – Saddle anaesthesia about the anus, perineum or genitals – Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance – Sensory level Inflammatory disorders (ankylosing spondylitis and related disorders) – Gradual onset before age 40 – Marked morning stiffness – Persisting limitation spinal movements in all directions – Peripheral joint involvement – Iritis, skin rashes (psoriasis), colitis, urethral discharge – Family history

6. Case 2 Mrs Helen Green is aged 35 years She has been decorating her bathroom ceiling She wakes up on Monday morning with a stiff neck and with pain in her neck and her right shoulder She then develops pain in her right arm from shoulder to wrist with numbness in her hand

7. Case 2 – some questions What is the structure of the spine in the neck? In which directions does this part of the spine move? What is the relationship between the spine and the nerves? Why does the patient feel pain in their arm? Why is damage to the spine at this level so dangerous?

8. Neck pain This is a common complaint, particularly in primary health care, with up to half the population experiencing neck pain at some muscular spasm: bad posture whilst sleeping, operating a word processor, sitting or carrying unbalanced loads may lead to acute spasm of the neck muscles. In extreme cases spasmodic torticollis may occur degenerative changes: degenerative changes in the cervical spine, cervical spondylosis may lead to neck pain, though symptoms are often related to use and can be relieved in part by supporting the neck for example with a collar. cervical nerve entrapment: traumatic and age related changes to the cervical vertebrae may lead to disc prolapse, osteophyte formation, apophyseal joint or ligamentous hypertrophy and these may in turn lead to mechanical entrapment of cervical nerve roots. This results in referred pain and abnormalities detectable on formal neurological examination. Conventional radiology is of limited use, except attempting to identify bony injury following acute trauma to the neck. Degenerative changes are commonly seen on plain radiology, and except in very young patients are of dubious significance. More helpful is magnetic resonance imaging which can identify tumours, atlantoaxial subluxation, abcesses, disc prolapse and injuries. For a majority of patients however with simple mechanical neck pain, MRI scanning fails to reveal any abnormalities.

9. Case 3 Mr David Smith is 72 years of age Six months ago he was diagnosed as having lung cancer He fell over and then developed pain in his lower back Today he has developed weakness in both legs and is unable to pass urine

10. Case 3 – some questions What is the relationship between the spine and the nervous system? Why is the control of the bladder so important to note? What other functions might be important to consider? Is the history of lung cancer important and why? Why does the patient develop weak legs? Why is it so important to detect spinal compression as early as possible?

11. Spinal cord compression Spinal cord compression is characterised by a combination of a progressive history of neurological deficit and a sensory level on examination. This is a lesion that causes lower motor neurone signs at the level of the lesion and upper motor neurone lesions below that level. It is a neurological emergency because: the final events are ischaemic, so they are fast and irreversible the patient may be left in a wheelchair, incontinent of urine Note that the commonest cause of acute cord compression is metastatic disease

12. Case 4 Mrs Josephine Green is 78 years of age 3 months ago she fell over and broke her wrist Last week she slipped on the stairs and landed on her bottom She now has severe pain in her back between her shoulder blades She is tender when the doctor taps her spine

13. Case 4 some questions What is the normal structure of bone? What is the structure of the bones in the spine? What happens when the bones loose normal strength? Which people are particularly prone to “thinning of the bones”?

14. Osteoporosis crush fracture These result from vertical compression and flexion, and may occur in the cervical, or thoraco-lumbar region. The majority are stable fractures. Sometimes they are pathological - associated with post- menopausal osteoporosis or spinal metastases. Osteoporosis is a loss of bone density sufficient to cause an increased risk of fracture. In contrast to osteomalacia, there is normal mineralisation of the bone. Osteoporosis is very common; prevalence increases with age, especially in post-menopausal women. Bone formation exceeds bone resorption in youth, but by the third decade of life there is a gradual loss of bone mass. Osteoporosis is therefore usually an age-related disease. It can affect both sexes, but women are at greater risk because the decrease in oestrogen production after the menopause accelerates bone loss to a variable degree.