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A CASE OF BACK PAIN By Ashraf Ebrahim ae622@ic.ac.ukinformation TASK1 TASK2 TASK3 Acending pain Science of referred Spinal cord pathway pain development TASK6 TASK5 TASK4 Communication Red flag symptoms Autonomic nervous /Clinical records systemHelpful knowledge Back Pain – why is this important - Very common >50%, good prognosis - Self-limiting - 10+ million sick days/year - Acute vs Chronic (>12 weeks) - Mechanical vs PathologicalHelpful knowledge Preventing back pain • Regular back exercises and stretches • Stay active - at least 150 minutes of exercise a week • Avoid sitting for long periods • Take care when lifting • Check your posture when sitting, using computers or tablets and watching television • Ensure the mattress on your bed supports you properly • Lose weight if you're overweight (through diet and exercise)Pre- reading NHS notes - Improves within few days, <6 weeks in 96% of cases - Common = Injury e.g pulled muscle - Sometimes = Slipped disc, sciatica, ankylosing spondylitis - Rare = Fracture, Tumour, Infectionreading Back pain – Self-treatment DO DON’T ✅Stay active and continue with daily ❌Do not stay in bed for long periods of time activities ✅Anti-inflammatories (ibuprofen) ✅Cold compress to reduce pain and swelling ✅Warm compress to relieve joint stiffness or muscle spasms ✅Do some exercises and stretches for back painPre- reading Back pain – When to get help GET MEDICAL ADVICE WHEN: • No improvement after treatment at home for a few weeks • Pain is affecting activities of daily living (ADLs) • Pain is severe or getting worse • Worried about the pain or struggling to copePre- reading Back pain – When to get help GET URGENT HELP FROM GP OR 111, RED = A&E/999: • numbness or tingling around your genitals or buttocks • pain, tingling, weakness or numbness in both legs • difficulty peeing • loss of bladder or bowel control – peeing or pooing yourself • chest pain • it started after a serious accident, such as after a car accident • a high temperature • unintentional weight loss • a swelling or a deformity in your back • it does not improve after resting or is worse at night • the pain is so bad you're having problems sleeping • pain is made worse when sneezing, coughing or pooing • the pain is coming from the top of your back, between your shoulders, rather than your lower backQuestion 1 Which of these options are all red flag symptoms of back pain? a. Chest pain, constipation, unintentional weight loss b. Urinary incontinence, a low temperature, chest pain c. Swelling in the back, high blood pressure, pain coming from the top of back d. Difficulty peeing, numbness around genitals, unintentional weight lossQuestion 1 Which of these options are all symptoms of back pain, where urgent help is required? a. Chest pain, constipation, unintentional weight loss b. Urinary incontinence, a low temperature, chest pain c. Swelling in the back, high blood pressure, pain coming from the top of back d. Difficulty peeing, numbness around genitals, unintentional weight lossPre- reading Back pain – Specialist treatment • Group exercise sessions and physiotherapy • Cognitive behavioural therapy (CBT) • Radiofrequency denervation o seals off some of the nerves in your back so they stop sending pain signals (only for long-term lower back pain) • Surgery (depending on cause of back pain)+ Task 1ing The science of pain: 3 main concepts 1. Somatotopic arrangement • Different areas of the somatosensory cortex of the brain are associated with different areas of the body 2. Contralateral arrangement • The left and right side of the somatosensory cortex of the brain are associated with the opposite side of the body 3. Affective neuroscience • Some brain regions when stimulated by the right kind of signal, can initiate a physiological and a motivation output+ Task 1ing Somatotopy Tongue 2 4 Face 3 1 Elbow 4 1 Foot 2 Hip Genitals 3 Hand+ Task 1ing Contralateral arrangement Dorsal column Spinothalamic decussates in decussates in MEDULLA SPINAL CORD Dorsal Ipsilateral Spinothalamic Contralateral DISCHelpful knowledge Back to basics Sensation Dorsal column pathway Ascending pathway Sensation (from BODY to BRAIN) Spinothalamic tract CNS Descending pathway Corticospinal tract (from BRAIN to BODY) Movement+ Task 1ing Two ascending pathways DORSAL COLUMN PATHWAY 1. Fine touch (discriminative) 2. Proprioception 3. Vibration SPINOTHALAMIC TRACT 1. Crude touch (non-discriminative) 2. Pain 3. TemperaturePre- reading Transduction Nociceptive neuron of the peripheral nervous system Transducer molecule Transduction: the process by which a stimulus is converted to an action potential (stimulus- mechanical, thermal chemical mechanical thermal, chemical)+ Task 1ing Spinothalamic tract – Pain PAIN Sharp pain Dull pain Arousal Sharp pain Fast (A-delta fibres) Pain Dull pain Slow (C-fibres) ArousalQuestion 2 A The figure below shows the potential pathways by which action potentials C may travel. D Identify the pathway by which an E action potential due to a dull pain on the right wrist would travel. FQuestion 2 A The figure below shows the potential pathways by which action potentials may travel. C Identify the pathway by which an action potential due to a dullEpain on the right wrist would travel. F 1 Dorsal horn Question 3 2 Left cerebral cortex 3 Right cerebral cortex Which is the correct order of the 7 step 4 Decussation at spinal cord pathway that describes the route of the action potential generated when you 5 Mechanoreceptor in right foot experience sharp pain on your right foot? 6 Thalamus a. 5, 7, 1, 4, 9, 6, 3 c. 5, 8, 1, 4, 9, 6, 2 7 Afferent nerve fibre (C-fibre) b. 5, 7, 4, 1, 9, 6, 2 d. 5, 8, 1, 9, 4, 6, 3 8 Afferent nerve fibre (A-delta fibre) 9 Ascend through spinothalamic tract 1 Dorsal horn Question 3 2 Left cerebral cortex 3 Right cerebral cortex Which is the correct order of the 7 step 4 Decussation at spinal cord pathway that describes the route of the action potential generated when you 5 Mechanoreceptor in right foot experience sharp pain on your right foot? 6 Thalamus a. 5, 7, 1, 4, 9, 6, 3 c. 5, 8, 1, 4, 9, 6, 2 7 Afferent nerve fibre (C-fibre) b. 5, 7, 4, 1, 9, 6, 2 d. 5, 8, 1, 9, 4, 6, 3 8 Afferent nerve fibre (A-delta fibre) 9 Ascend through spinothalamic tractPatient history – Paul Bennett PC • Worsened lower back pain (ongoing for years, but now pain is overbearing and awoken with numbness to his right foot) • ‘Haven’t had a wee all day’ • Pins and needles in both legs HPC • Leg weakness (ongoing) • New paraesthesia in both legs • Pain on lying down • Urinary retention PMHx • Lower back pain (ongoing for years) • Physiotherapy, exercises and painkillers alleviate symptomsask 2 The case – Referred pain Mechanism: 1. Pain stimuli sent from visceral tissues (organs) Dorsal horn = 2. Action potential sent through sensory sensory afferent pathway afferents up the spinothalamic tract to the brain 3. Convergence theory: visceral sensory neurones can converge with the somatic sensory neurones as well Spinothalamic tract 4. Stimulus that was from a visceral tissue is perceived by the brain as though it was from skin/ muscleask 2 The case – Referred pain Differentials for lower back pain: 1. Vertebra – compression fracture 2. Spinal cord – spinal cord compression 3. Nerve roots – radiculopathy 4. Lumbar muscles – lumbar muscular strain 5. Aorta – ruptured abdominal aortic aneurysm (AAA) 6. Kidneys – kidney stones 7. Pancreas – pancreatitisBack pain – Anatomy Highlight = common Red = Back pain – Causes Emergency VERTEBRA SPINAL CORD • Compression fracture • Spinal cord compression • Spinal stenosis • Malignancy • Spondylolysis/ spondylolisthesis • Vertebral discitis/osteomyelitis (infection) • Inflammatory spondyloarthropathy NERVE ROOTS LUMBAR MUSCLES • Herniated nucleus pulposus • Lumbar muscular strain/ sprain • Cauda equina syndromeask 3 The case – Differential diagnoses 1. Mechanical back pain • Caused by abnormal stress and strain on muscles of the vertebral column • Triggered by certain movements/ positions, comes and goes 2. Radiculopathy • A nerve root is pinched as it exits the spinal column • Usually unilateral 3. Cauda Equina Syndrome • Lumbosacral nerve roots are severely compressed • Usually bilateralask 3ask 3 Cauda Equina Syndrome – Overview • Lumbosacral nerve roots that form the cauda equina in the spinal canal become compressed (usually by a centrally prolapsing intervertebral disc) • Causing lower motor neuropathy affecting the bladder sphincters, bowel sphincters, and lower limbs • Bilateral symptoms L4 L5 • L4/L5 and L5/S1 are the most common sites of nerve compression in CES S1 • Medical emergencyask 4 Cauda Equina Syndrome – Overview Cauda equina consists of spinal nerveL2-L5, S1-S5 and the coccygeal nerve.ask 4 Cauda Equina Syndrome – Red flags 1. PAIN 2. WEAKNESS 3. INCONTINENCE • Bilateral sciatica • Bilateral neurological • Difficulty initiating deficit in lower limbs micturition causing urinary retention with • Saddle paraesthesia overflow urinary • Laxity of anal sphincter incontinence • Erectile dysfunction • Sensation loss of rectal fullness causing faecal incontinenceask 4 Cauda Equina Syndrome – Red flags explained 1. PAIN Why bilateral? Central disc herniation → nucleus • Bilateral sciatica pulposus displaced from annulus fibrosus → compression onto spinal nerves within spinal canal → bilateral symptoms Sciatica: Nerve pain in the leg caused Why sciatica? by an irritated or compressed sciatic nerve The sciatic nerve is formed by the combination of motor and sensory fibres from spinal nerves L4 to S3.Cauda Equina Syndrome – Red flags explained Why neurological deficit? 2. WEAKNESS Why anal sphincter laxity Both the lumbar and sacral • Bilateral neurological and erectile dysfunction? plexus supply innervation to deficit in lower limbs S2, 3, 4 innervates the anal the lower extremity sphincter, internal urethral • Saddle paraesthesia sphincter and causes • Laxity of anal sphincter erection of the penis Why saddle paraesthesia? • Erectile dysfunction “S2, 3, 4 keeps the 3 Ps off Saddle sensation is around the floor” (pee/poo/penis) the buttocks and anus. It is supplied by the S3 to S5 nerve rootsask 4 Cauda Equina Syndrome – Red flags explained 3. INCONTINENCE • Difficulty initiating micturition causing urinary retention with overflow urinary incontinence • Sympathetic nerves at L1-L3 stops you peeing (Sympathetic Stops) • Sensation loss of rectal • Parasympathetic nerves at S2-S4 makes you pee (Parasympathetic Pees) fullness causing faecal • CES commonly occurs at L4/L5 and L5/S1 incontinence • Parasympathetic function would be impaired but sympathetic function preserved, therefore you can #stoppeeing but you can’t pee → urinary retentionask 4 Cauda Equina Syndrome – Red flags explained 3. INCONTINENCE • Difficulty initiating micturition causing The “poodendal” nerve controls sensation from urinary retention with your rectum/ anus overflow urinary incontinence “S2, 3, 4 keeps the 3 Ps (pee/poo/penis) • Sensation loss of rectal fullness causing faecal incontinenceExplain this contradiction! The lower urinary tract is innervated by 3 sets of peripheral nerves: 1. Lumbar sympathetic nerves, which relax the bladder and contract the internal urethral sphincter (L1-L3) 2. Pelvic parasympathetic nerves, which arise at the sacral level of the spinal cord, contract the bladder, and relax the internal urethral sphincter (S2- S4) VS 3. Pudendal nerves, which contract the “S2, 3, 4 keeps the 3 Ps off the floor” (pee/poo/penis) external urethral sphincter (S2-S4)Investigations and treatment Investigations • The most important investigation for cauda equina syndrome is an MRI spine • A CT myelogram may be considered situations whereby MRI is contraindicated Treatment • Treating patients within 48 hours after the onset of the syndrome provides a significant advantage in improving sensory and motor deficits as well as urinary and rectal function Adverse long term effects: Loss of bowel and bladder control, ED, neurogenic pain, lower limb weakness, psychological issues etc.ask 5 Cauda Equina Syndrome – Red flags • Bilateral sciatica. • Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion. • Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence. • Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence. • Perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia). • Laxity of the anal sphincter. • Consider an assessment of anal tone but note that this does not need to be performed in primary care. • Erectile dysfunction.Question 4 Mr Hemsworth has developed severe backpain due to nerve compression in his spinal cord at the level of the T11 vertebrae. How is this most likely to affect his micturition? a. Problems in both the initiation and termination of micturition b. Problems only in the initiation of micturition c. Problems only in the termination of micturition d. No problem in either initiation or termination of micturitionQuestion 4 Mr Hemsworth has developed severe backpain due to nerve compression in his spinal cord at the level of the T11 vertebrae. How is this most likely to affect his micturition? a. Problems in both the initiation and termination of micturition b. Problems only in the initiation of micturition c. Problems only in the termination of micturition d. No problem in either initiation or termination of micturitionFEEDBACKask 6 Communicationask 6 Clinical recordsPost- reading Clinical records – why? MDU top tips • Conduct a full examination and make a record that this has been done. • Consider the red flags • If red flags are present, the patient needs to be seen in hospital urgently • If no red flags are present, make a record in the notes to demonstrate you have actively considered the condition • If, after the assessment, the patient is being managed as having simple mechanical back pain, give safety netting advice including advising the patient of the red flag symptoms and the importance of seeking urgent medical attention if these appear. Again, try to make a record in the notes of the specific safety netting advice that has been given.Post- reading Final tips – Stats questions 1. Recognise them 2. Don’t panic 3. Read the question carefully – be careful of negatives 4. Time management 5. Practice! Significance is p < 0.05 Question 5 Lower back pain can be treated in a number of ways. Two alternatives are brief intervention or extended intervention. The table below contains data from a study a) 0 b) 1 investigating the relative effect of these two treatment approaches on health and c) 2 disability one year after treatment. d) 3 e) 4 How many outcomes measures are significantly improved to a greater extent by the brief intervention compared with the extended intervention? Question 5 Lower back pain can be treated in a number of ways. Two alternatives are brief intervention or extended intervention. The table below contains data from a study investigating the relative effect of these two a) 0 treatment approaches on health and b) 1 disability one year after treatment. c) 2 How many outcomes measures are d) 3 e) 4 significantly improved to a greater extent by the brief intervention compared with the extended intervention?Question 6: At what vertebral level does the spinal cord end? a. L1 b. L2 c. L3 d. S1Question 6: At what vertebral level does the spinal cord end? a. L1 b. L2 c. L3 d. S1Question 7: What investigation does a patient with CES require urgently? a. Full blood count b. MRI spine c. CT spine d. Urea and electrolytesQuestion 7: What investigation does a patient with CES require urgently? a. Full blood count b. MRI spine c. CT spine d. Urea and electrolytesQuestion 8: Describe the parasympathetic action on bladder function a. Detrusor contraction and internal urethral sphincter contraction b. Detrusor relaxation and internal urethral sphincter contraction c. Detrusor relaxation and internal urethral sphincter relaxation d. Detrusor contraction and internal urethral sphincter relaxationQuestion 8: Describe the parasympathetic action on bladder function a. Detrusor contraction and internal urethral sphincter contraction b. Detrusor relaxation and internal urethral sphincter contraction c. Detrusor relaxation and internal urethral sphincter relaxation d. Detrusor contraction and internal urethral sphincter relaxationQuestion 9: Which of the transduction processes is the TRPV1 molecule associated with? a. Chemo-transduction only b. Thermo-transduction only c. Both chemo-transduction and thermo-transduction d. Neither chemo-transduction nor thermo-transductionQuestion 9: Which of the transduction processes is the TRPV1 molecule associated with? a. Chemo-transduction only b. Thermo-transduction only c. Both chemo-transduction and thermo-transduction d. Neither chemo-transduction nor thermo-transduction chemical thermalQuestion 10: Which patient has CES? a. 26yo male with back pain worse on movement b. 68yo female with back pain and right foot paraesthesia c. 75yo male with urinary incontinence d. 45yo male with back pain and numbness in both upper thighsQuestion 10: Which patient has CES? a. 26yo male with back pain worse on movement b. 68yo female with back pain and right foot paraesthesia c. 75yo male with urinary incontinence d. 45yo male with back pain and numbness in both upper thighsSummary checklist ❑List the common and uncommon causes ❑Explain the mechanism of referred pain of back pain, identifying the medical ❑Identify where the cauda equina is emergencies located and where CES normally occurs ❑Identify each step in the dorsal column ❑Identify the red flags of CES and spinothalamic pathways, including dull pain vs sharp pain ❑Explain the effects of CES on micturition, understanding the sympathetic and ❑Explain somatotopic arrangement, parasympathetic pathways of bladder contralateral arrangement and affective control neuroscience