666 a m u a r t d n a s c i d e a p o h t r O 667 a m u a r t d n a s c i d e a p o h t r O Fig 1. The ligaments around the elbow joint \200\224posterolateral view of the right elbow (1) and anteromedial view of the left elbow (2). Stability of this joint is mainly from bon y factors, though ligaments do play an important part \200\224eg the annular ligament wraps around the head of the radius (which can pop out in a \200\230pulled elbow \200\231), and also allows smooth prona- tion/supination. Remember that the joint is made up from 3 artic ulations: radio-humeral, proximal radioulnar, and humeroulnar. Fig 2. Lateral x-ray of the elbow showing degenera- tive changes of osteo-arthritis. There is loss of joint space, osteophyte formation, bony deformity, and subchondral sclerosis. Mo vement is painful and severely restricted. Norfolk and Norwich University Hospitals (NNUH) Radiology Department. The wrist and hand Dupuytren \200\231s contracture Progressive, painless \201 brot- ic th ickening of the palmar fascia with skin puckering and tethering. Ring and little \201 nge rs are chie \202 y aff ect- ed. It is often bilateral and symmetrical. As thickening occur s there may be MCP joint \202 exion. If interphalan- geal joints are aff ected the hand m ay be quite disabled. Surgery (eg fasciectomy) aims to remove aff ected pal- mar fascia and release contractures. As a guide, if he cannot place his palm \202 at on a \202 at sur face (Hueston \200\231s table-top test), refer for surgery. There is tendency for recurrenc e.29 Ganglia These smooth, multilocular swellings are cysts containing jelly-like \202 ui d in communication with joint capsules or tendon sheaths. Treatment is not needed unless th ey cause pain or pressure (eg on median or ulnar nerve at the wrist, or lateral popliteal n erve at the knee). They may disappear spontane- ously. Local pressure may disperse them (tr aditionally a blow from a Bible!) Aspiration via a wide-bore needle may work, or they may b e surgically dis- sected out, which may give less recurrence;30 problems include painful sc ars, neurovascular damage (esp. in palmar wrist ganglia), and recurrence.31 De Quervain \200\231s disease This refers to stenosing tenosynovitis (thickening and tightening) of the abductor pollicis longus and extensor pollicis brevis tendons (at the anterior border of t he anatomical snuff box) as they cross the distal radial styloid. Pain is worst when these tendons are stretched (eg lifting a teapot), and is more proximal than that from osteoarthr itis of the 1st carpo- metacarpal joint. Finkelstein \200\231s sign is pain elicited by sha rply pulling on the re- laxed thumb to cause ulnar deviation.32 Cause: Unknown but symptoms can be exacerbated by over use of the tendons (eg wringing clothes). Treatment: First try rest (thumb spica splint), ice, and NSAIDs. Hydrocortisone injection at tendon site during the 1st 6 months of symptoms is eff ective in 90% of patients. If injection (p710) and rest fail to relieve, decompression of the tendons is pro- vided by splitting the tendon sheath s. >80% do well post-op.33,34 Trigger \201 nger (tendon nodules) Probably caused by a swe lling of the \202 exor tendon or tightening of the \202 exor tendon sheath. Ring and mi ddle \201 ngers are most commonly aff ected, and the thumb especially in babies and child ren. Swelling of the tendon sheath, along with nodule formation on the tendon, proximal to the A1 pulley ( \201 g 3) prevents the smooth gliding of the tendon. As a result the tendo n \200\230catches \200\231 causing the \201 nger to lock in \202 exion. As extension o ccurs, the nodule moves with the \202 exor tendon, but then becomes jammed on the proxima l side of the pulley, and has to be \202 icked straight, so producing triggering. \201 \227: Simple immobilization is initial treatment of choice: if severe, steroid injection in to the region of the nodule may be tried (not if the patient is a child, has renal failure or diabetes). Risk of recurrence is high, so surgery may be needed.35,36 Volkmann \200\231s ischaemic contracture follows compartment syndrome or interruption of the brachial artery near the elbow (eg after supracondylar fracture of humerus, p740). Muscle necrosis (especia lly \202 exor pollicis longus and \202 exor digitorum profundus) results in contraction and \201 brosis causing a \202 exion deformity at wrist and elbow, with forearm pronat ion, wrist \202 exion, thumb \202 exion & adduction, digital metacarpophalangeal joint extension, and interphalangeal joint \202 exion. \200\207Suspect compartment syndrome if a damaged arm has no radial pulse, and passive \201 nger extension is painful (a crucial sign, p736). Treatment: Remove constricting splints, warm other limbs (promote va- sodilat ation). If pulse doesn \200\231t return within 30min, explore the artery. Treating contract ures: release of compressed nerves tendon lengthening and trans- fers to restore lost fu nction.37 668 \200 Causes/associations Often multifactorial: \200 Genetic (AD) \200 Smoking \200 Diabete s \200 Antiepileptics \200 Peyronie \200\231s disease (OHCM p722) a m u a r t d n a s c i d e a p o h t r O 669 a m u a r t d n a s c i d e a p o h t r O Fig 1. Cross-sectional view of the wrist showing the contents of the carpal tunnel and the extensor tendons of the hand. When trying to describe local anatomy of the hand, it is easi er to use the terms ulnar and radial, rather than medial and lateral, which can cause confu sion. Dorsal refers to the posterior surface, while palmar re- fers to the anterior surface .1 A1 A2 C1 Fig 2. Axial T1-weighted wrist MRI; note labels on \201 g 1. Norfolk and Norwich University Hospitals (NNUH) Radiology Dept. A3 Flexor tendons pulley mechanisms ( \201 g 3) In order to stop the long \202 exor tendons of the hand bowing when the \201 ngers are \202 exed, the \201 ngers have a number o f pulleys (that are well-placed thickenings in the \202 exor sheath) attached to the bone s and volar plates beneath. Named morphologically as either \200\230A \200\231 for annular , or \200\230C \200\231 for cruciate, there are 5 A-pulleys and 3 C-pulleys. The most impo rtant are A2 (which is at the proximal end of the proximal phalanx) and A4 (at the middle o f the middle phalanx), both of which need to be preserved during any surgery to prevent bow ing of the \202 exor tendons. Sometimes mountaineers, and others hanging on by their \201 ngertips, partially damage the A2 pulley (typically). Stop climbing! Apply ice and bud dy- taping/splinting. Then do only light exercises (rubber donut squeezes; mild stretches) until 2wks after pain and swelling subside. Visible bowing of the tendon may indicate that surgery is needed; get help MRI. 1 The International Federation for Societies for Surger y of the Hand recommends the term \200\230palmar \200\231 over \200\230volar \200\231. C2 A4 C3 A5 Fig 3 Pulley system. Examination of the back History The commonest musculoskeletal complaint is back pain. Atten tion should be paid to the nature of the pain, exacerbating and relieving factors, and the history of onset. \200\207It is important to know if bowel or bladder function is aff ecte d (signifying cord or cauda equina compression and should set alarm bells ringing: refer at once (MRI in <4h). See MINIBOX, p676, for other sinister symptoms). With low back pain, it is not uncommon for pain to radiate down the leg (sciatica), and may be accompanied by ner ve root signs (see below). Examination With the patient standing and wearing only underwear , inspect the back for abnormality and palpate for local tenderness and deformity. Movement s assessed are forward \202 exion (stretch forward to touch toes with knees straight) \200\224look to see how much movement is due to back \202 exion and how much by \202 ex ion at the hips \200\224with back \202 exion the back has a gently rounded contour. On be nding fully forwards, expansion of a line drawn from 10cm above L5 to 5cm below it by <5cm is \201 rm and quanti \201 able evidence of movement restriction. Look for a rib hump \200\224a sign of scoliosis); extension (arch spine backwards); lateral \202 exion (lean sideways so hand moves down corresponding thigh) and rotation (keep pelvis \201 xed but m ove shoulders round to each side in turn \200\224mostly from the thoracic spine). Movement at the cos- tovertebral joints is assessed by the diff erence in chest expansion between ma ximal inspiration and expiration (normal=5cm). Iliac crests are grasped by the examiner and compressed to move sacroiliac joints and see if this repro- duces the pain. Compare leg le ngth; quantify discrepancy and muscle wast- ing (measure thigh and calf circumference). If there are leg symptoms ensure neurologic assessment of L4 (knee re \202 ex), L5 (weakness of ankle and great toe dorsi \202 exion, sensory loss in medial foot and 1st/2nd toe web s pace) and S1 (an- kle re \202 ex, weakness of plantar \202 exion) roots. Straight leg ra ising Why? To test for an underlying herniated disc (98% of which will be at the L4 \200 \223S1 levels) How? Keeping the knee extended, lift the pa- tient \200\231s leg off the cou ch and note the angle to which the leg can be raised be- fore eliciting pain. If 30 \200 \22370 , Las gue \200\231s sign is said to be positive. Mechanism? This stretches the sci atic nerve and causes root pain (a characteristic lancinat- ing pain distributed in the rel evant dermatome, and made worse by coughing or sneezing). The crossed straight leg raise in volves lifting the unaff ected leg. If this reproduces pain in the aff ected side it is sai d to be positive. It is less sensitive but more speci \201 c for an underlying herniated d isc. Alternatively: sit the patient up in bed with legs out in front. This can be done whil e examin- ing another system, and may prove pain-free if the patient is not genuine. All th ese tests may still give false positives and negatives, hence the importance of a good hist ory combined with the examination.38 Other parts of the body to examine \200\207Remember t o examine hip joints (p680) and gait. Other relevant areas are the iliac fossae (important in days when tuberculous psoas abscesses were common), abdomen, pelvis, rectum, and major a rteries. The commonest tumors to metastasize to bone are: breast, bronchus, kidney, thyroid , and prostate so it may be relevant to examine these. Tests For acute low back pain seen i n primary care, tests are not usually needed in the \201 rst 4 weeks. FBC, CRP (infection ), ESR (if high, think of metas- tases or myeloma, and do electrophoresis bone marrow as pirate), alkaline phosphatase (high in Paget \200\231s disease and tumors), calcium. In the absence of trauma, MRI is the gold-standard imaging investigation and is sometimes availab le in the primary care setting. Radioisotope scanning is a non-speci \201 c investigation, but may reveal \200\230hot spots \200\231 of tumor or pyogenic infection. On the followin g pages you can \201 nd: \200 Kyphosis/scoliosis \200 Causes of back pain \200 Mana gement of back pain \200 Speci \201 c and sometimes sinister back pain. 670 \200 a m u a r t d n a s c i d e a p o h t r O 671 Laid \202 at by a wealth of evidence Entering the search term \200\230back pain \200\231 in Pubmed delivers 42,099 entries (at the time of writing), with 392 meta-analyzes! Holdin g back throes of exaspera- tion: where do you start, what do you look for, and how can you \201 lter? (See also p636.) Does this wealth of evidence exist because back pain is such a common condition, because there are so many diff erent treatment options, or because we a re not yet to be able to off er de \201 nitive therapy to our pa- tients? Before embarking on a more targeted search, an answer dawns that it is most likely a combination of all the se factors, unfairly pitted against a complex mix of anatomy (just think of the number of s tructures in the back that can be injured), individuality, susceptibility, cause, tolerabil ity, and treat- ment effi cacy. a m u a r t d n a s c i d e a p o h t r O As we stand up to the challenge laid down by evolution (and search en- gines alike), those without back pain can count themselves lucky, while those struck horizontal by our primitiv e postural problems try not to think of the irony that we are lying in the plane in which o ur vertebral column originally worked! Kyphosis and scoliosis Kyphosis is a spinal thoracocervical \202 exion, sometimes with a lordosis of the lumbar spine. Treat the underlying cause if indicated. NB: congenital kypho sis is much less common than congenital scoliosis, but is more serious, as cord compression and paraplegia sometimes develop rapidly, eg during adolescence.39 Scoliosis This is later al spinal curvature with secondary vertebral rotation. The chief cause is idiopathic, and n ormally involves muscle spasm. Classi \201 cation: \200 Idiopathic (may be infantile, ju venile or adolescent). \200 Congenital (failure of formation or segmenta- 672 \200 Causes of kyphosis \200 Osteoporosis \200 Spina bi \201 da \200 Calv \200\231s and Scheuermann \200\231s osteochondritis (p702) \200 Cancer; wedge fractures \200 Tuberculosis; polio \200 Pag et \200\231s disease \200 Ankylosing spondylitis a m u a r t d n a Remain in light \200 \200 Kyphosis: anterior curva- (kyphos = hump-backed) \200 Lordos is: posterior curva- (lordos = bent back) \200 Scoliosis: lateral curvature (skolios = cu rved) tion \200\224see BOX, opposite). Neuromuscular (neuropathic, eg UMN/LMN le- sion or myopathic, eg cerebral palsy or muscu- l ar dystrophy). ture of the spine Syndromic (eg Marfan \200\231s, OHCM p720, or neuro \201 - s c i d e a p o h t r O ture of the spine bromatosis, OHCM p518). Other (eg tumor, infection, trauma). Idiopathic scoliosis There is lateral curvature (a Cob b angle) of the thoracic or lumbar spine of >10 . It is usually accompanied by a degree of rotation of the spinal column. Adolescent idiopathic scoliosis (AIS) is the most common sp inal deformity; girls are more often and more severely aff ected than boys and the convexit y is more commonly to the right. Complications in later life revolve around pain, cosmesis, and impaired lung function. Thoracic problems tend to give more severe deform- ity than lu mbar. Rib deformity causes a characteristic hump on the convex side of the curve which beco mes manifest on asking the patient to bend forwards. Curvature increases while the aff ecte d person continues to grow, so usually the earlier the onset the worse the deformity. of the spine Since the advent of screening, scoliosis has been detected in 1.5 \200\2233%; of these only 6% progress. The younger the child, and the greater the Cobb an- gle at presentation, the more the risk of progression \200\224double curves progress more than single curves, and a scoliosis in girls is more likely to progress than one in boys. Thoracolumbar or lumbar cu rves progress the least. Treatment is needed in 2.75 : 1000 screened. Where curvatures are >30 and growth is com- pleted, or >20 if growth is in progress, orthopedic referral is recommended. When curvatures are progressing, attempts to halt it may be made using a Bosto n or Milwaukee distraction-derotation brace (particularly for double curves, or if the apex of the curve is higher than the 8th thoracic vertebra1) until the child is old enough for any spinal surgery that may be indicated. NB: it can be hard to persuade a child to wear a brace for the \200\20620h/day that is optimal! \200\224bracing will not correct the deform ity but has a role in slowing/ preventing curve progression. Surgery involves deformity cor rection with spinal fusion and sta- bilization (pedicle screws and longitudinal rods). Intr a-operative spinal cord monitoring reduces the most feared post-op complication \200\224par aly- sis (it now occurs in 0.2%). \200\207When scoliosis in youth gives pain (especially a t night), exclude osteoid osteoma (p699), osteoblastoma, spon- dylolisthesis (p674), and sp inal tumors. Fig 1. Kyphoscoliosis. 673 The spine, development and evolution During development, the vertebral column initially has a primary cur- vature (anteriorly co ncave, as for the thoracic and sacral curvatures in red), then goes on to develop sec- onda ry curvatures in the cervical and lumbar regions (in blue). The normal vertebral body count is 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and then some coccygeal (3 \200\2235). The re is some variation, eg L5 can be fused to the sacrum (sacralization) or S1 can be distinc t from the sacrum (lumbariza- tion), though total numbers remain constant (even across some mamma- lian species, especially in the cervical region \200\224eg the giraff e also has 7 cer- vical vertebrae).40 Atlas Axis a m u a r t d n a s c i d e a p o h t r O 7th cervical 1st thoracic Remember that there are 8 cervi- cal spinal nerve roots, with the C1 root arising from abov e the C1 ver- tebra, the C8 root from above the T1 vertebra, and from T1 onwards the root e xiting below the corresponding vertebra. This occurs because dur- ing development the incip ient spinal nerves develop through the embry- onic sclerotomes, with the upper part of the C1 sclerotome joining with the last occipital sclerotome to form the base of the occipital bone, and the lower part of the C1 sclerotome form- ing the C1 vertebra with the upper C2 s clerotome \200\224and so on. Defective in- duction of vertebral body formation on one side of the body (=hemiver- tebra) may cause a severe scoliosis, and incorrect or absent inducti on of vertebral arch closure by the neural tube causes the degrees of spina bi- \201 da ( p140). 12th thoracic 1st lumbar 5th lumbar Coccyx Fig 2. The vertebral column. 1 Boston braces worn for >18h/day do prevent progression of large curves at a mean of 9.8 y ears after bracing is discontinued.41 Sinister back pain: \200\207p678 Causes of back pain Backache is often from low back strain or degenerative disease. Local p ain is typically deep and aching (from soft tissue and vertebral body irritation). Radicula r pain is stabbing, and is caused by compression of the dorsal nerve roots, and projects in a dermatomal distribution. Other causes: Retroperito- neal (duodenal ulcer, pancreatic can cer, aortic aneurysm; pain is often lumbo- dorsal and spine movements pain-free and full); neoplasia (eg myeloma); local infection; disc lesions; arthritis; osteoporosis/osteomalacia ; renal colic. Mechanical pain The spine is a complex series of articulations ( \201 g 2, and \201 g 1 on p673), with spongy disks between vertebral bodies acting as shock absorb- ers, and a multitude of articulating facet joints. Problems in one part aff ect function o f the whole. Spasm of vertebral muscles can cause signi \201 cant pain. Upright posture pr ovokes big forces on the spine, eg when lifting, and disks may rupture (if young), vertebra e fracture (elderly) or soft tissues tear (low back strain). NB: with low back strain the e xact mechanism may be elusive; if there are no sinister features ( \200\207p676) take time to explain the diagnosis and management; see p676 for imaging guidance. Disc prolapse ( \201 g 1). Lumbar disks are those most likely to rupture (esp. L4/5 & L5/S1). Typically, on e is seized by severe pain on coughing, sneezing, or twisting a few days after back strain (onset may be insidious). Pain may be con \201 ned to the lower lumbar area (lumbago), or may radiate to buttock or leg (sciatica) if the herniated nucleus pulposus compresses a ner ve root. Signs: Forward \202 exion (p670) and extension limited, lateral \202 exion \200\224unilaterally and inconstantly. With L5/S1 prolapse, S1 root compression causes calf pain, weak foot plantar \202 exion, \200\201sensation (pinprick) over sole of foot and back of calf, and \200\201ankle jerk. With L4/5 prolapse (L5 root compression), hallux ext ension is weak and sensation \200\201 on outer dorsum of foot. If lower lumbar disks prolap se centrally, cauda equina compression (p770, and MINIBOX) may occur. Tests: MRI (or CT) if intervention is contemplated \200\224 \200 as an emergency if cauda equina compres- sion i s suspected \200\224or if rest fails and symptoms are severe, with CNS signs such as re \202 ex or sensory changes, or muscle wasting. Treating disc prolapse: Brief rest and early mobilization + pain relief (p676) is all that is needed in 90% ( physiotherapy). Discect omy is needed in cauda equina syndrome, pro- gressive muscular weakness, or continuing pain .42 See BOX on p677 for surgical options. Spondylolisthesis There is displacement (usually forward) of one lumbar vertebra upon the one below (usually L5 on S1, sometimes palpable). Causes: Spondylolysis (defect in pars interarticularis of neural arch); congenital mal- for mation of articular processes, osteoarthritis of posterior facet joints (older people). Ons et of pain with or without sciatica is often in adolescence ham- string tightness and ab normal gait. Diagnosis is by plain radiographs. Treat- ment may involve wearing a corset, o r nerve release and spinal fusion. Lumbar spinal stenosis (LSS) and lateral recess stenosis ( \201 gs 2 & 3). Facet joint osteoarthritis (the only synovial joints in the back) may p roduce general- ized narrowing of the lumbar spinal canal or simply of its lateral recesses . Un- like the pain of lumbar disc prolapse, this causes: \200 Pain worse on walking with aching and heaviness in one or both legs causing the person to stop walking (= \200\230sp inal claudication \200\231) \200 Pain on extension. \200 Negative straight leg raising test. \200 Few CNS signs. Tests: MRI (CT and myelography are less good options). Treat- m ent: Canal decompression (removing its posterior wall) gives good results if NSAIDs, epidur al steroid injections, and corsets (to prevent exaggerating the lumbar lordosis of standing ) fail to help.43 674 \200 a m u a r t d n a s c i d e a p o h t r O Danger signs of cauda equina compression \200 Saddle-area sensation \200\201 \200 Inconti nence/retention of feces or urine \200 Poor anal tone (do PR) \200 Paralysis sensory loss \200 Do MRI within 4h 675 Notes on the cauda equina (=horse \200\231s tail) The cord tapers to its end, the conus med ullaris, at L1 in adults. Lumbar and sacral nerve roots arising from the conus medullaris f orm the cauda equina. These spinal nerve roots separate in pairs, exiting laterally through the nerve root foramina, providing motor and sensory innervation of the legs and pelvic or gans. Compression may be from extrinsic tumors, primary cord tumors, spondylosis, spinal st enosis, achondroplasia, \202 uorosis, central disc herniation, trauma, spinal subarachnoi d hemorrhage, abscess, tuberculoma, or vertebral collapse secondary to malignancy.44 a m u a r t d n a s c i d e a p o h t r O Normal lateral recess (3 \200\2235 mm) Stenosed lateral recess (<2 mm) Pedicle of L5 Superior articular facet L5 Inferior articular facet of L4 L4 lamina L4 spinous process Fig 1. Axial MRI image at the L5/S1 level show- ing a right-sided paracentral disc prolapse . Observe the displaced nerve roots within the CSF- \201 lled dural sac (arrow). Remember that CSF is white on T2-weighted MRI. Fig 2. L5 cross-section showing lateral recess stenosis. This is usually caused by degenera tive disease of the facet joint, but rarely can be from congenitally shortened pedicles. Picture courtesy of Mr Mark Brinsden, FRCS. Fig 3. Cross-section CT images at L5, one with spinal stenosis (right). Observe the diff er ence in spinal canal shape and dimensions caused by osteoarthritis of the facet joints post erolat- erally. Factors contributing to spinal stenosis: disc prolapse, spondylolisthesis, hypertrophy of the ligamentum \202 avum. Identify the spinal canal contents at this level , including the the- cal sac and the two L5 nerve root sheaths that occupy the lateral rece sses. Images courtesy of Mr Mark Brinsden FRCS. Management of low back pain Back pain is common. 80% of Western people get it at some stage in their lives. 50 per 1000 in- dustrial workers have time off work because of it each yea r. In the UK it accounts for 11 million lost working days/yr ( 3.8 billion/yr in lost pro- duction). A GP expects 20 people per 1000 on her list to consult with it each year (only 10% are referred to hospital). Fewer than 10% of those referred to a specialist need surger y. Physi- otherapy may be carried out in hospital or gen- eral practice. Most back pain is self-limiting: of those attending GPs, 70% are better after 3 weeks, 90% by 6 weeks, irresp ective of treatment. But remember: the cause of back pain can be sinis- ter \200\224cancer, infection, or cord or cauda equina compression \200\224and an approach is needed that dete cts these promptly. Age is important: only 3% of those aged between 20 and 55 have \200 \230spinal pathology \200\231 (eg tumor, infection, in \202 ammatory disease) compared wit h 11% of those <20yrs, and 19% >55yrs. \200\207Pain brought on by activity and re- lieved by rest is rarely sinister. See MINIBOX. Re- fer those with any suggestion of cord or cauda equina compression (p770), or with deteriorating unilateral signs at once. If cancer or in fection is suspected, refer promptly. \200\207Do FBC, ESR, LFT etc (p670) whenever pain la sts >4weeks, whatever the age. Imaging In general, don \200\231t do imaging such as CT/MRI before blood tests, and reserve for when symptoms are chronic (ie >4 weeks, unless signi \201 cant trauma or there are alarm features, see BOX). Plain radiographs correlate poorly with symptoms, and irradiate gonads. 25% of asymptomatic adults show lumbar degenerative c hanges on plain \201 lms; 50% have coincidental bulging disks.45 Treating biomechanical b ack pain Often hard! \200\230Get on with your life within the limits of the pain \200\231 gives better results than physiotherapy with lateral bending exercises. Avoid bed-rest afte r the 1st 48h (a board under the mat- tress helps). Avoid slouching. Advise on how to rise from lying, avoid stooping, bending, lifting, and low chairs.46,47 Analgesia breaks the pai n \200\223muscle spasm cycle (paracetamol \211 4g/24h PO, NSAID, eg ibuprofen 400mg/8h PO pc or nap- roxen.1 Opioids may be needed early. Warmth helps, as does swimming in a warm pool. If acute spasm persists, try a muscle relaxant such as diazepam 2mg/8h PO for a shor t while, but warn about side eff ects (eg drowsiness).48 Cognitive therapy in groups (p372 \200\2236) helps tackle unhelpful beliefs about backache and fears about retarting activity . Antidepressants can help refrac- tory pain, but not level of functioning.49 Physiotherapy in the acute phase can \200\201pain and spasm. In convalescence, give education on liftin g and exercises to strengthen the back muscles. Many consult osteopaths or physiotherapists or chiropractors for manipulation, but studies show that it is unlikely to provide relief beyond that attained from other standard therapies.50 Referral for epi- dural anesthesia, a nd corsets may help + orthopedic referral; but note that spinal fusion is no better than in tensive rehabilitation.51 676 \200 Backache is sinister if \200 \200\20520 or \200\20655 years old \200 Violent trauma \200 Alternating sciatica (both legs involved) \200 Bilateral sciatica \200 Weak legs \200 Weight loss \200 Fever o r unwell \200 ESR \200\200 (>25mm/h) \200 Taking oral steroids \200 Progressive, cont inuous, non-mechanical pain \200 Systemically unwell \200 Drug abuse or HIV +ve \200 Spine movement in all a m u a r t d n a directions painful Pain unrelated to me- s c i d e a p o h t r O chanical events Local bony tenderness \200 CNS de \201 cit at more than one root level Pain or tenderness of thoracic spine Bilateral signs of nerve root tension Previous neoplasia 1 COX-2 inhibitors have an uncertain role; heart SE are problematic so don \200\231t use in arteriopaths. Naproxen with misoprostol, eg Napratec is one choice as gastric protection from of misoprostol translates into \200\201mortality. \200\207Avoid in fertile women. A lternative: nabumetone 1g PO at night; in severe pain 0.5 \200\2231g in morning as well; el derly 0.5 \200\2231g daily. In one study, the adjusted odds of death for Arthrotec was 1. 4 and 3 for naproxen.52 Naproxen may be associated with fewer thrombotic events. If current peptic ulcer and NSAID unavoidable, try omeprazole + celecoxib. 677 Surgery for lumbar disc prolapse There are a number of procedures that can be performed for the treatment of lumbar disc prolapse: \200 Lumbar microdiscectomy ( \201 g 1) is the m ost common procedure, and in- volves microscopic resection of the protruding disc (nucleus pulposus) from a posterior approach, with the patient anesthetized in the prone position wi th lumbar spine \202 exion. Occasionally the overlying medial facet is partially removed. Complication rate is 2 \200\2234% (infection, bleeding, nerve damage). \200 Endoscopic d iscectomy ( \201 g 2) is similar in principle to lumbar microdis- a m u a r t d n a s c i d e a p o h t r O cectomy, though is less invasive. Laser discectomy involves radiographically assisted placement of a deliv- ery device into t he disc, through which a laser can be introduced to remove disc material. Lumbar disc arthoplasty (replacement with an arti \201 cial disc) is a concept that has be en around since the late 1980s, and is becoming more common.53 \200 Interspinous spacers relieve pressure that cause the disc to protrude by causing distraction of the spinous proc esses (= \200\230dynamic stabilization \200\231).54 Longterm eff ectiveness is unknown. Chemonucleolysis, which used to be more common, involves injection of chymopapain (a proteo lytic derived from papaya) into the nucleus pulpo- sus \200\224it has been part of practice since the 1960s. There has been contro- versy surrounding the procedure, with shadows hang ing over the effi cacy of the techniques and side eff ects of the agent (eg possible anaphy laxis). It is less invasive than other techniques though is probably less eff ective than s urgical discectomy.55 Fig 1. Lumbar microdiscectomy. Reproduced with kind permission of Dr Aaron Filler; Do You R eally Need Back Surgery? OUP, 2004. Fig 2. Endoscopic discectomy. Kindly provided by Medtronic Sofamor Danek, Inc. METRx Syst em incorporates technology developed by Gary K. Michelson, MD. Speci \201 c and sometimes sinister back pain 678 \200 Typical causes of back pain according to age: 15 \200\22330yrs Prolapsed disc, trauma, frac tures, ankylosing spondylitis (OHCM, p552), spondylolisthesis, pregnancy Prolapsed disc, cancer (lung, breast, prostate, thyroid, kidne y) Degenerative, osteoporosis, Paget \200\231s disease (OHCM p699), malignancy, myeloma (OH CM p362); lumbar artery atheroma (which may itself cause disc degeneration) >30yrs >50yrs Rarer causes Spinal stenosis; cauda equina tumors; spinal infection (usually staphylococcal , also Proteus, E. coli, Salmonella typhi, TB). Often there are no systemic signs of infect ion. Spinal tumors These may be of spinal cord, meninges, nerves, or bone. They may be prim ary, secondary, lymphoma, or myeloma. They may compress the cord, causing pain, lower motor neuron signs at the level of the lesion, upper motor neuron signs and sensory loss below \200\224or bowel and bladder dysfunc- tion. Peripheral nerve function may be impaired resul ting in pain along the course of the nerve, weakness, hypore \202 exia & \200\201sensatio n (p762). With cauda equina involvement there is often urinary retention saddle anesthes ia (p770). When the deposit is in the spinal canal and there is no bone involve- ment, ther e may be no pain, just long tract signs. When bones of the back are involved there is progr essive, constant pain and local destruction of bone. Metastases tend to aff ect cancellous bone, but focal lesions cannot be seen on radiographs until 50% of bone mass is lost. There may be muscle spasm and local tenderness to percussion. Bone collapse may result in deform ity, or cause cord or nerve compression. Tests: ESR; PSA; electrophoresis (for myeloma); LF T. Plain radiographs; CT; MRI; isotope bone scans; bone biopsy. a m u a r t d n a s c i d e a p o h t r O In those with past cancer and current back pain, it is best to do a bone scan \201 rst ( \201 g 1), with plain radiographs of any hot spots suggesting metastases. Pyo genic spine infections This is a notoriously diffi cult diagnosis as all signs of infection may be absent (eg no fever, tenderness, or WCC \200\200, but the ESR is often \200\200). It may be secondary to other septic foci. Pain occurs, and movement is restricted by spasm. It is usually an infection of the disc space (discitis). Risk factors: Diabetes mellitus, immunosuppression, urinary surgery, or cath- eterization. Half of infections are staphyloco ccal; Streptococcal, Proteus, E. coli, Salmonella typhi and TB also occur. Tests: ESR \200 \200; WCC \200\200; radiographs shows bone rarefaction or erosion, joint space narrowing subligamentous new bone formation. Technetium bone scans and MRI ( \201 g 2) are better. Treatment: As for osteomyelitis (p696), resting the back with bed rest, brace, or plaster j acket. Surgery may be needed. Spinal TB Rare in those born in the West, this tends to aff e ct young adults, giving pain, and stiff ness of all back movements. ESR \200\200. Abscesses and cord compression may occur (Pott \200\231s paraplegia). Radiographs show narrow disc s paces and local osteoporosis early, with bone destruction leading to wedging of vertebrae l ater. In the thoracic spine, paraspinal abscesses may be seen on radiographs, and kyphosis on examination; with lower thoracic or lumbar involvement abscess formation may be related to psoas muscle in the \202 ank, or in the iliac fossa. MRI (not CT) is the ideal way to delineate cord compression. Treatment is anti-TB drugs (eg for 1yr; p160) + abscess drainag e. Fixation + bone grafting, or metal rods, plates, or wires needs highly specialized servi ces. If a syrinx (tubular cavity) develops, complete CNS recovery is not expected.56 Centra l disc protrusion This neurosurgical emergency is suggested by bilat- eral sciatica, perine al or \200\230saddle \200\231 anesthesia and disturbance of gut or blad- der function. \200\207Prompt decompression may prevent permanent incontinence. 679 Diagnostic triage: which grOUP encompasses your patient? Simple lumbar pain: \200 Aged 20 \200\22355 with Nerve root pain: \200 One leg hurting more than the back \200 Radiation to foot/toes \200 Hip \202 exion reproduces the pain in leg; \200 Localized neurological signs \200\230mechanical \200\231 backache, eg caused by twisting and worse on moving a m u a r t d n a s c i d e a p o h t r O Patient well in himself; no fevers; no weight loss \200\207For features of potentially sinister back pain, see MINIBOX, on p676. \200\207Sig ns demanding immediate (same-day) referral: gait or sphincter distur- bance; saddle anesthe sia \200\224these suggest cauda equina compression. Fig 1. Bone scan showing multiple metastases from prostatic cancer, including in \201 ltra tion of the pelvis, ribs, left femur and spinal column. Fig 2. Axial T2-weighted MRI of the lumbar spine showing an epidural abscess in the posteri or portion of the spinal canal causing mild stenosis. University Hospital NNUH NHS Trust. Norfolk & Norwich University Hospital (NNUH) NHS Trust. Why do some people get intractable back pain? 39% of adults have, or have had, an intermitt ent chronic back problem, and much energy is expended on frequently fruitless searches for the causes list- ed opposite. Imaging may be non-speci \201 c (subclinical disc protrusion , facet joint arthritis, or minor spondylosis). Risk factors for chronicity: \200 Smoking \200 Psychological morbidity \200 Low income/social class Be cautious of blaming sitti ng at work for chronic back pain. Meta-analyzes do not \201 nd in favor of this popular a ssociation.57 Coexisting cardio-respiratory disease \200 Poor work conditions \200 Number of children (for women and men). Vascular problems may underlie chronicity (hence associations with smok- ing and heart dise ase), and pain may be maintained by involvement of the sympathetic chain, which may mediate hyperaesthesia, hyperpathia (excess pain from minor noxious stimuli), allodynia (pain from minor skin stimula- tion) \200\224but surgical sympathectomy often only provides temporary relief. This implies central neuromodulation of stimuli producing a complex regional pain syndrome. Dorsal horn receptor \201 elds may expand and have their thresholds changed by peripheral injury, so pain is more intense, and appreciated over a wider area than simple a natomy would predict.58