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Back problems 207
BACK PROBLEMS
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support the diagnosis?
Q3: What additional features in the history would you seek to support a particular
diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 4.9 –
The teenager with thoracic back pain
A 13-year-old girl has complained of increasing back pain in the lower thoracic/interscapular spine. This
is aggravated by her schoolwork, in particular when she is doing homework. She is able to do games at
school and this only moderately aggravates her symptoms.
CASE 4.10 –
The young adult with a trapped nerve
A 32-year-old man had minor twinges of back pain over the course of the past week. Earlier today he
was lifting his golf clubs out of the boot of his car when he experienced a searing pain and was unable
to straighten up; he had severe pain radiating all the way from the back down to his right foot.
CASE 4.11 –
The pathological fracture
A 72-year-old otherwise healthy woman had a minor fall when she slipped on some spilt milk on her
tiled kitchen oor. She experienced very severe lower back pain and has been brought in by ambulance
from home because she is unable to weight bear. She mentions that for the last couple of weeks she
has had a strange woolly feeling in the right leg.
CASE 4.12 –
DIY gone wrong
A 53-year-old man was attempting his own loft conversion and fell backwards through the loft hatch.
He has severe lower back pain and has been brought in from home with spinal immobilization.
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208 Trauma and orthopaedic surgery
OSCE Counselling cases
OSCE COUNSELLING CASE 4.5 –
‘Doctor, I have terrible backache. The
scan shows that I have a slipped disc.
Don’t I need an operation to take the
slipped disc away?’
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Back problems 209
Key concepts
THE SURGICAL SIEVE
As mentioned before in the section ‘The painful hip’, the surgical sieve is helpful when approaching
patients with back problems.
Children and teenagers are most likely to have problems of developmental or rarely, but very
importantly, malignant origin. Young adults tend to experience spinal problems associated with early
degenerative change, and elderly people have problems caused by either osteoporosis or malignancy.
Trauma, naturally, can affect any age group. Serious spinal injuries are very often seen after high-
velocity or high-energy transfer road trafc accidents, or falls from heights by people attempting DIY.
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210 Trauma and orthopaedic surgery
Answers
Clinical cases
CASE 4.9 –
The teenager with thoracic back pain
A1: What is the likely differential diagnosis?
During the adolescent growth spurt aches and pains can come and go; however, if they are persistent
they must be investigated because failure to recognize problems such as a slipped upper femoral
epiphysis can be catastrophic.
A2: What issues in the given history support the diagnosis?
Thoracic back pain is either postural in origin or may result from Scheuermann’s disease, an
osteochondritic process affecting the midthoracic vertebrae, which is often asymptomatic and only
discovered in later life as an incidental radiological nding. Another unlikely, but important, possibility is
that of a malignant or infective process. Given that the patient in question is otherwise well and able to
take part in activities, the most likely diagnosis is that of poor posture or Scheuermann’s disease.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Malignancy affecting the thoracic spine is usually secondary to a previously known cancer; however,
primary tumours do occur, originating in the bone marrow, or any of the musculoskeletal, vascular or
neural elements of the spine. Rest pain and night pain support the diagnosis of infection or malignancy.
The fact that posture (i.e. sitting at a desk and working) aggravates the symptoms strongly favours
a purely mechanical origin. Other features indicating serious pathology are symptoms of nerve
compression, altered sensation and altered power.
A4: What clinical examination would you perform and why?
The spine specically should be examined with the patient standing, seated and lying prone.
Neurological examination of the limbs would exclude any evidence of spinal or spinal nerve root
involvement. Inspection of the spine will give a clear indication of any kyphotic changes that are
commonly associated with Scheuermann’s disease or lateral curvature of the spine – scoliosis – which
may have remained undetected through the patient’s early childhood. Postural scoliosis, which is
habitual rather than a structural problem with the spine, will correct when the patient forward exes to
try to touch the oor. A true structural scoliosis will actually be accentuated by this manoeuvre. Careful
palpation of the spine will elicit any areas of tenderness.
A5: What investigations would be most helpful and why?
Plain AP and lateral radiographs of the spine to include the whole spine should be taken if a
structural scoliosis is dened. Then MRI would be indicated to further dene any suggestion of
bony destruction. Scheuermann’s disease is recognized by simple anterior wedging of the thoracic
vertebrae.
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Back problems 211
A6: What treatment options are appropriate?
For management of Scheuermann’s disease and thoracic pain of a purely postural origin, physiotherapy
is all that is needed. The prognosis is excellent.
CASE 4.10 –
The young adult with a trapped nerve
A1: What is the likely differential diagnosis?
The most likely differential diagnosis is that of a prolapsed intervertebral disc, which usually occurs at
the level of L5/S1, trapping the S1 nerve root.
A2: What issues in the given history support the diagnosis?
A prolapsed intervertebral disc can occur against a long-standing history of mechanical back pain in
young adults, with a simple event such as stooping to lift a comparatively light weight causing the
degenerate disc to prolapse. This results in nerve root entrapment, inammation and radicular pain as
described.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Specic questions should be asked about previous episodes of lower back pain. In mechanical back
pain, the lower back pain is a dominant symptom and such referred pain as the patient experiences is
normally vague and referred into one or both thighs, usually anteriorly. The pain from a prolapsed disc
resulting in nerve root entrapment is usually extreme. The resulting referred leg pain is worse than the
back pain and may radiate all the way to the foot in the case of ‘sciatica’ or down to the knee in the
front of thigh in the case of ‘femoralgia’. Lower lumbar disc prolapses are much more common because
the lower lumbar spine is subject to large stresses in ordinary everyday life. Femoralgia occurs as a result
(a) (b)
Figure 4.12 Radiograph from a teenager with thoracic back pain: Scheuermann’s disease.
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212 Trauma and orthopaedic surgery
of a prolapsed disc higher in the lumbar spine and, although less common, is readily recognizable if it is
sought.
A4: What clinical examination would you perform and why?
Neurological examination is mandatory. The patient may not be able to stand but should be encouraged
to do so if he or she can. If possible the patient should be asked to walk on tiptoes. This is the most
reliable way of assessing plantar exion (S1 nerve root-innervated muscular strength). Careful inspection
of the back will show the lumbar spine to have a loss of lordosis as a result of paraspinal muscle spasm
and there will often be a scoliosis concave to the side in which the nerve root is entrapped, resulting
from greater muscle spasm on that side.
Further clinical examination requires a thorough neurological examination of the patient’s lower
limbs plus saddle (urogenital/perianal) area, including digital rectal examination.
Tests for sciatic nerve root tension or femoral nerve root tension should be left until the end of the
examination.
Power inhibition often occurs as a result of the extreme pain and so it is useful for the patient to be
given a potent analgesic, before power testing is carried out.
In an L5 nerve root entrapment there may be weakness in great toe dorsiexion and foot inversion.
In an S1 nerve root entrapment there may be weakness in plantar exion and foot eversion. The ankle
jerk may be lost in either of the above cases. With femoralgia the quadriceps may be weak and there
may be loss of the patellar tendon jerk. Sensory blunting is usually in a characteristic dermatomal
distribution.
Examination of the perianal area is crucial. If the disc prolapse is central rather than lateral, cauda
equina syndrome may result. In this case the patient will have no desire to void if nerve root entrapment
affects those nerves mediating sensation to the bladder. Painless retention occurs and, unless surgical
decompression is carried out urgently, incontinence and loss of sexual function will be permanent. Such
patients usually have bilateral lower leg sciatic pain and bilateral perianal numbness with loss of anal
tone. Careful clinical examination will often demonstrate the presence of a full bladder in a patient in
whom there is no desire to void. Passage of a catheter is usually easy and pain free, with little sensation
of catheter insertion experienced by the patient. A large volume of urine is usually drained.
Last, sciatic nerve root tension signs can be identied by the straight-leg raise. Care must be taken to
do this gently and it is often a good idea to start with the pain-free leg, and to watch the patient’s face.
Lift the pain-free leg into the air gently, while encouraging the patient to relax. When he experiences
pain enquire whether it is in the back or the ipsilateral or contralateral leg. Pain in the ipsilateral leg is
a cross-over sign when examining the pain-free leg, suggesting a central disc prolapse. Keep the foot
in its current position and then ex the knee. This should relieve leg pain. Note whether the pain is
experienced solely in the back because this goes against sciatic nerve root tension.
Repeat the process with the contralateral leg. Bow-string signs and dorsiexion of the foot to elicit
pain again can also be performed after relieving pain by exing the knee. However, the simple straight-
leg raise test is normally enough to conrm or refute the diagnosis.
A5: What investigations would be most helpful and why?
A plain lateral radiograph of the lumbar spine is indicated to exclude any unexpected destructive
malignant pathology. The gold standard investigation is MRI.
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Back problems 213
A6: What treatment options are appropriate?
In spite of the catastrophic nature of presentation most cases of sciatica will respond to analgesia
supported by a muscle relaxant/antispasmodic and progressive physiotherapy. Long periods of bed rest
should be avoided.
The patient should be encouraged to return to work as early as possible and to stop smoking.
Interestingly, both of these are important features in long-term recovery.
In patients who fail these conservative measures a discectomy is indicated.
Cauda equina syndrome must be treated as an emergency. Urgent MRI should be performed with
prompt spinal decompression by an appropriately skilled orthopaedic or neurosurgical spinal surgeon.
CASE 4.11 –
The pathological fracture
A1: What is the likely differential diagnosis?
The differential diagnosis is restricted essentially to the diagnoses underlying pathological spinal
fractures. The most common example would be an insufciency fracture caused by osteoporosis.
Other origins of pathological weakness in the vertebrae include malignant deposits, which may be
primary or secondary. A common primary deposit is myeloma. Secondary deposits usually originate in
the breast, thyroid, lung, prostate or kidney.
A2: What issues in the given history support the diagnosis?
A history of previous insufciency fractures would strongly support a diagnosis of an osteoporotic
fracture. A history of a known malignancy would indicate the possibility of a tumour deposit.
In the given history the feeling of abnormal sensation in one lower limb hints at involvement of spinal
nerve roots, which is not typical in osteoporotic fractures.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Specic questions should be asked about the past medical history to elicit the problems outlined above,
plus general questions about the patient’s overall health, well-being, weight loss etc.
(a) (b)
Figure 4.13 Young adult with a prolapsed intervertebral disc.
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214 Trauma and orthopaedic surgery
A4: What clinical examination would you perform and why?
Clinical examination should be performed with the patient lying supine and carrying out the spinal
immobilization precautions for the injured area. It must be presumed, in the presence of a fall, a history
suggestive of a fracture and abnormal neurological symptoms, that the spinal injury is potentially
unstable. Further movement without appropriate care could easily result in worsening neurological
damage.
Otherwise neurological examination should be carried out exactly as for Case 4.10.
A5: What investigations would be most helpful and why?
Plain radiographs are essential, and may demonstrate a simple wedge compression consistent with an
osteoporotic insufciency fracture. In the history presented, it is quite possible that the AP view of the
lumbar spine would demonstrate loss of the pedicle at the level of the fracture – a radiological nding
suggestive of malignant destruction.
Further investigations should include FBC, ESR, biochemistry screen including liver function tests,
CRP, urine for Bence Jones proteins and protein electrophoresis of the serum.
Magnetic resonance imaging is mandatory to dene the extent of any soft tissue mass associated
with a pathological fracture and to assist in planning of surgery for decompression of such a mass and
stabilization of the spine to allow for mobilization of the patient.
A6: What treatment options are appropriate?
If the woman’s fracture is entirely attributable to osteoporotic change, she simply needs to be given
analgesia and gently and progressively mobilized thereafter. Care should be taken to ensure that she has
appropriate treatment for her osteoporosis to help reduce the risks of further fractures.
In the case of spinal cord or spinal nerve root compression with an associated fracture caused by
a malignant deposit, surgical decompression after pre-operative treatment with steroids to reduce
associated tumour-related swelling would have a reasonable chance of restoring lower limb function
in this woman. The more severe the pre-operative nerve impairment, the less the chance of complete
resolution of symptoms with spinal decompression and operative stabilization of the spine – hence the
importance of careful handling of the patient pre-operatively.
Figure 4.14 Radiograph showing a pathological spinal fracture.
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Back problems 215
CASE 4.12 –
DIY gone wrong
A1: What is the likely differential diagnosis?
The most likely differential diagnosis is a burst fracture – an unstable fracture of one of the lumbar
vertebrae; less likely is a stable wedge compression fracture.
A2: What issues in the given history support the diagnosis?
It is impossible from the history to determine whether the fracture sustained is stable or unstable unless
there is neurological injury. Neurological injury is a sign that the associated fracture is unstable.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Not applicable
A4: What clinical examination would you perform and why?
Full spinal precautions must be taken, including immobilization of the cervical spine.
The patient should have a thorough neurological examination in the supine position, paying
particular attention to loss of sensation, reexes and power in the lower limbs, and the urogenital
triangle as described above.
In addition, specic examination of the feet, ankles, knees and hips should be carried out because in
a fall from a height, typical associated injuries include fractures of the calcaneum, distal articular surface
of the tibia (plafond), tibial plateau, femoral condyles, hips and pelvis.
A5: What investigations would be most helpful and why?
Plain radiographs will help conrm the level of the spinal fracture and may give important information
as to whether or not, in the patient who is neurologically intact, the fracture is stable.
It is important to understand that a fracture may be completely unstable but the patient
neurologically completely normal.
(a) (b)
Figure 4.15 Radiographs showing a fracture of L1 (a) lateral view (b) AP view.
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216 Trauma and orthopaedic surgery
Features suggesting instability include loss of the anterior vertebral body height: greater than 30 per
cent of the posterior vertebral body height suggests posterior element injuries. Again this hints at the
potential for unstable motion of this injured spinal segment.
On the AP radiograph, wedging in the lateral direction suggests a rotational rather than a true
wedge compression mechanism, further indicating instability. Clear-cut signs of instability on the plain
radiographs are those of a retropulsed fragment encroaching on the spinal canal and loss of posterior
vertebral height; both of these features are visible on the lateral view. On the AP view, the signs are
widening of the distance between the pedicles in comparison to the vertebrae above and below.
Computed tomography will dene the precise architecture of the bones at this level and facilitate
planning of spinal surgery if this is deemed necessary.
Further radiographs should be carried out of the feet, tibial plateaux, hips, pelvis and so on if areas of
tenderness or deformity have been identied.
A6: What treatment options are appropriate?
Full spinal immobilization should be continued until the spine either is recognized as being stable or
becomes stable through healing or surgical intervention.
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