Neck and back pain

Epidemiology

• Point prevalence 5% for low back pain and 9% for neck pain
• Back pain is number one cause of disability and neck pain number four

Risk factors on history

• Pain >6 weeks – Tumor, infection
• Age <18 or >50 – Congenital anomaly, tumor, infection
• Major trauma – Fracture
• Minor trauma in elderly or rheumatological disease – Fracture
• Hx of cancer – Tumor
• Fever and rigors – Infection
• Weight loss – Tumor, infection
• IVDU – Infection
• Immunocompromised – Infection

Risk factors on history

• Night pain – Tumor, infection
• Unremitting pain, even when supine – Tumor, infection
• Incontinence – Epidural compression
• Saddle anaesthesia – Epidural compression
• Severe/pprogressive neurological deficit – Epidural compression
• Anticoagulants/coagulopathy – Epidural compression
• Headache, shoulder or visual disturbance = PMR/GCA
• Anterior neck pain/chest pain = Angina

Risk factors on exam

• Fever – Infection
• Writhing in pain – Infection, vascular cause
• Unexpected anal laxity – Epidural compression
• Perianal/perineal sensory loss – Epidural compression
• Major motor weakness/gait disturbance – Nerve root or epidural compression
• Positive SLR – Herniated disk

Clinical features of neck pain

• Divide into uncomplicated, neck pain with radiculopathy (single nerve root) and/or myelopathy (spinal cord lesion, stenosis or compression)
• Uncomplicated MSK pain
  • Tenderness of involved muscles
  • Atrophy or thinning of shoulder muscles evident
  • Pain increases with shoulder abduction on side of neck pain (radicular pain can be eased by this manouvre
  • Repetitive or new arm/shoulder activity preceding
  • Recent injury or awkward positioning e.g. sleeping funny or standing in weird position for extended period of time
  • Pain accompanied by stiffness of involved muscle group

Clinical features of neck pain

• Examination
  • MSK causes tend to be unilateral causing asymmetrical limitation of movement
  • Localised ipsilateral neck pain towards side of head movement – suspect zygapophyseal joint irritability
  • Localised ipsilateral neck pain away from side of head movement – suspect ligamentous/muscular injury

Clinical features of neck pain

• Radiculopathy
  • Often described as sharp, burning, intense pain that radiates to the trapezius, periscapular area or down the arm
  • Typically pain and sensory changes along dermatomal distribution
  • Weakness and/or paraesthesias can arise weeks after pain onset
  • Abduction relief test – Arm on top of head relieves radicular pain on that side – may indicate soft disc protrusion causing radiculopathy
• Myelopathy
  • May have neck pain progressing insidiously with clumsy hands, gait disturbances and sexual or bladder dysfunction

Clinical features of neck pain

• Examination
  • Spurling’s sign – Pushing down on top of head with neck in extension and head leaning towards symptomatic side elicits pain towards or down the arm. 90% specific; 45% sensitive
  • Lhermitte’s sign – Flex neck forward until chin meets chest or pain stops movement. Electric shock sensation down both arms +- paraesthesias is positive and indicates possible cord compression
  • Reflex changes suggest radiculopathy/myelopathy
  • Hyperreflexia, positive Babinski, clonus, gait disturbance, sexual or bladder dysfunction, lower limb weakness, impaired fine hand movements and upper/lower limb spasticity all suggest myelopathy
  • Hoffman’s sign – Flicking tip of middle finger while in hand in neutral position yields flexion of thumb and index finger in pinching motion and suggests an upper motor neuron lesion
  • Bilateral or multilevel involvement usually implies serious pathology

Cervical radiculopathy

Algorithm (UpToDate)

• Traumatic – CT C-spine
• Neurology to suggest cervical myelopathy = Urgent MRI
  • Lower extremity weakness
  • Gait or coordination difficulties
  • Bladder or bowel
  • Lhermitte’s sign
  • DDx: Cervical spondylotic myelopathy, MS, malignancy, infection

Algorithm (UpToDate)

• Other Red Flags
  • Infection: MRI
  • Cancer: MRI
  • Rheumatological: ESR/CRP
• Radiculopathic sensory/motor/Spurling – Conservative
• Stiffness, reduced ROM, muscle tenderness – Conservative
• Later
  • If progressive or severe neurological changes or no change over 6 weeks with conservative therapy
    • If radicular – MRI
    • If non-radicular – C-spine plain film +- MRI

Neck imaging

• No imaging – Acute, uncomplicated, non-radiculopathic, non-myelopathic, atraumatic neck pain
• Plain films – In chronic neck pain without hx of trauma, those with neck pain and prior hx of malignancy or neck surgery and those with neck pain and pre-existing spinal rheumatological disorders
• CT – Trauma
• MRI – Chronic neck pain with neurological signs or symptoms OR if plain films suggest bone or disc margin destruction, cervical instability or epidural abscess/malignancy suspected

Differential of neck pain

• Mechanical
• Cervical disc herniations
• Cervical spondylosis and stenosis
• Cancer of C-spine
• Cervical myofascial pain syndrome
• Other
  • Myelopathy: Epidural abscess, osteomyelitis, transverse myelitis, epidural haematoma, ischaemic heart disease, MS, amyotrophic lateral sclerosis, subacute combined degeneration, syrinx, 
  • Radiculopathy: Carpal tunnel syndrome
• Meningitis
• Deep neck infection
• Cervical artery dissection
• Torticollis

Cervical disc herniation

• Nucleus pulposus protrudes through annulus fibrosis posteriorly, producing acute radiculopathy or, rarely, a myelopathy
• Protrusion is usually confined by the posterior longitudinal ligament but can occasionally extrude through as ‘free fragments’
• Direct posterior ruptures can produce progressive myelopathy
• More common posterolateral herniations cause acute cervical radiculopathy
  • Most frequently C5/6 (C6 nerve root) and C6/7 (C7 nerve root)

Cervical disc herniation

• Present with neck pain, headache, pain distributed to shoulder/medial scapular border, dermatome pain and dysaesthesia
• Examination may reveal fasciculations, atrophy and weakness in myotomal distribution + loss of reflexes
• If myelopathy nay have lower extremity hyperreflexia, positive Babinski and loss of sphincter control
• Spurling’s maneuver and Valsalva may replicate symptoms
• MRI required for definitive diagnosis

Cervical spondylosis and stenosis

• Cervical spondylosis = degenerative disc disease/osteoarthritis
• Progressive, degenerative disease with loss of cervical flexibility, neck pain, occipital neuralgia, radicular pain and rarely progressive myelopathy
• Can be diagnosed if any one of three findings on plain films:
  • Osteophytes
  • Disc space narrowing
  • Facet disease
• High prevalence in asymptomatic individuals
• Predisposes to progressive osteoarthrosis of the cervical spine, joint instability and incongruous joint motion
• Most commonly C5-6 and C6-7

Cervical spondylosis and stenosis

• Osteophytic spurs can encroach:
  • Posteriorly on spinal canal, producing cervical myelopathy
  • Laterally on intervertebral foramen producing cervical radiculopathy
  • Anteriorly on oesophagus producing dysphagia
  • Horner’s syndrome, neck pain, painless upper extremity myotome weakness and chest pain all possible
  • Neurological findings typically gradual unless recent trauma

Cancer of cervical spine

• Consider in chronic neck pain, especially unremitting night time pain
• Lung, breast, prostate, lymphoma and multiple myeloma most common
• Myelopathy is rarely caused by metastases (usually disc or degenerative disease)
• Plain films have 10-17% false negative rate but may show vertebral body destruction, lytic lesions of pedicles and compression fractures
• MRI is standard for detection of spinal epidural metastatic disease and cord compression
• Cancer patients with evidence of bone or disc margin destruction need MRI

Cervical myofascial pain syndrome

• Typically pain in neck, scapula and shoulder with non-dermatomal radiation into upper extremity
• Tender spots and trigger points are often evident
• Typically in psychological distress and specific personality traits

Treatment of uncomplicated neck pain

• Act as usual, avoid precipitating activities, NSAID’s, short-coarse of oral opioids if severe and GP follow-up
• Minimal evidence for allied health/alternative therapies although individual patients may find benefit
• Soft collars are not advised for whiplash
• Therapy for myofascial pain syndromes should be directed at both muscular tension and psychobehavioural issues

Treatment of cervical radiculopathy

• Conservative activity modification and oral analgesia
• Immobilisation not evidence based
• F/u with GP and consideration of referral to neurosurg/ortho if required
• No evidence for short coarse oral steroids
• Epidural steroid injections may be helpful for chronic cervical radiculopathy when other treatments have failed
• If symptoms fail to respond to conservative therapy, MRI is warranted and if imaging correlates with symptoms, surgery may be advised
• Indications for admission to hospital:
  • Progressive upper extremity weakness, especially C7 distribution (triceps weakness/weak reflex), intractable radicular pain not responding to treatment

Treatment of cervical myelopathy

• Discuss with specialist re: decompressive surgery
• Cervical spondylotic myelopathy causes greatest degree of impairment and disability in continuum of spondylosis
• Myelopathy is the most common of spastic paraparesis in patients older than 55
• Steroids and radiation therapy for spinal epidural metastases will depend upon time course and aetiology

Torticollis

• Spasm of sternocleidomastoid
• Sudden onset, severe unilateral pain
• Lateral flexion of neck to one side and head rotated to opposite side
• Rx
  • Place assistant’s hand on side of patients chin (opposite side to rotation)
  • Ask patient to push with chin against resistance
  • Assistant gradually reduces resistance until chin past midline
  • Repeat 3-4 times
  • Simple analgesia

Clinical features of thoracic and lumbar back pain syndromes

• Acute <6 weeks: 80-90% resolve within this time frame. Any longer indicates possibility of more serious disease
• Subacute 6-12 weeks: 90% resolved by end of 12 weeks (sciatica takes longer)
• Chronic > 12weeks
• <50% of patients unrecovered by 6 months will return to work

Differential

• Spinal
  • Muscular/ligamentous strain
  • Disc herniation
  • Osteoporotic fracture
  • Malignancy
  • Vertebral infection
  • Transverse myelitis
• Non-spinal
  • AMI
  • Pancreatitis
  • Pneumonia
  • Aortic dissection
  • AAA
  • Renal colic/pyelonephritis

Historical risk factors

• Age <18: More likely congenital, spondylolysis, spondylolisthesis and Scheuermann’s kyphosis
• Age >50: More prone to fractures (>65 highest risk), spinal stenosis and intra-abdominal pathology e.g. AAA
  • Age >65 = LR+ 2 for fracture
  • Age >70 = LR+ 11 for fracture
• Sciatica indicates nerve root impingement or disc herniation below L3 nerve root with radicular pain into buttock or thighs. Often accompanied by motor or sensory deficits

Historical risk factors

• Trauma – May be minor in the elderly
  • Visible contusion = LR+ of 20 for fracture
• Systemic complaints
  • Fever, chills, night sweats, malaise, undesired weight loss = infection, systemic rheumatological disease or cancer
  • More concerning for infection if recent bacterial infection (UTI, pneumonia and especially skin abscess), recent GU or GI procedure, immunocompromised, IVDU, alcoholism, renal failure or diabetes
  • IVDU is a substantial risk factor for spinal infection so assume this until proven otherwise
  • AAA, pancreatitis, posterior lower lobe pneumoniae, nephrolithiasis and renal infarct
• Pain features
  • Dull aching pain, worse with movement and better with rest is typical of benign back pain
  • Night pain, waking from sleep and unrelenting despite analgesics and rest = tumor or infection (often missed)
  • Worse with rest
  • Pain worse with cough, Valsalva, sitting and relieved by lying suggests disc herniation
  • Spinal stenosis presents with bilateral sciatic pain worsened by walking, prolonged standing and back extension with relief from rest or sitting forwards
• Neurological deficit by hx
  • Bowel or bladder incontinence suggests epidural compression syndrome such as spinal cord compression, cauda equina or conus medullaris syndrome
  • Large post-void residual >100mL indicates overflow incontinence, which when combined with lower back pain suggests neurological compromise and epidural compression syndrome
  • New sexual dysfunction in association with back +- leg pain is suggestive of cord compression
• PMHx
  • Cancer
    • Back pain precedes neurological loss in 95% of cases
    • Pain radicular in 80% of cases
  • Osteoporosis
  • Only 1/3 of patients diagnosed with spinal malignancy have a known history of cancer

Examination risk factors

• Fever – Sensitivity for infection is low (27% for tuberculous osteomyelitis to 50% for pyogenic osteomyelitis, 60-70% for pyogenic discitis and 66-83% for spinal epidural abscess
• Examine back for skin changes of infection
• Consider fracture or bacterial infection if point tenderness to vertebral percussion
• Straight leg raise –
  • Test for radicular pain arising from nerve root irritation (L4-S2)
  • With patient supine and contralateral hip and knee flexed, examiner lifts extended leg
  • Positive test reproduces the leg-dominant pain described by the patient
  • Test is positive regardless of the angle reached
  • Screening examination for herniated disc
    • 1/3 of positive SLR and a negative sitting knee extension test have an MRI-proven herniated disc
    • Positive SLR is 68-80% sensitive for L4-5 or L5-S1 herniated disc
    • Positive crossed SLR is highly specific but insensitive for nerve root compression by a herniated disc and increases the risk of cauda equina

Neurological examination

• Sensation in dermatomes – Light touch and if any issue continue on to pinprick, temperature, proprioception and vibration
  • L1 – Underpants
  • L2 – Anterior thigh
  • L3 – Knee
  • L4 – Medial shin
  • L5 – Lateral shin
  • S1 – Lateral foot
  • S2 – Behind knee
  • S3/4/5 – Perianal

• Assess strength based on nerve roots
  • L4 – Knee extension
  • L5 – Dorsiflexion of great toe and foot (heel walking)
  • S1 – Plantarflexion of great toe and foot (toe walking)
• Reflexes
  • Knee – L3/4
  • Ankle – S1
• Saddle sensation on all patients (between upper buttocks cleft) and subsequent DRE if abnormal or other concerns re: cauda equina
  • Pin-prick sensation MUST be tested not just light touch

4 specific nerve root patterns

Back Pain Syndromes (Dr Hamilton Hall)

• 4 Patterns of Pain
  • Pattern 1
    • Back dominant
    • Pain aggravated by flexion
    • Constant or intermittent pain
    • Normal neurological examination
    • Likely discogenic
    • PEP or PEN (see below) just helps guide mobility exercises
  • Pattern 2
    • Back dominant
    • Aggravated by extension
    • Pain always intermittent
    • Never worse with flexion
    • Normal neurological examination
    • Likely posterior elements involved
  • Pattern 3
    • Leg Dominant
    • Constant pain
    • Pain aggravated by movement
    • Positive neurological findings (positive SLR or femoral stretch +- motor/sensory changes)
    • Femoral or sciatic nerve root compromise
  • Pattern 4
    • Leg Dominant
    • Intermittent Pain
    • PEP = Usually subsiding sciatica or longstanding damage to normal nerve activity
    • PEN = Neurogenic claudication
• Need to be very specific in questioning around constant pain or intermittent (defined as any period of time, however short, in which pain resolves completely)
• Need to be very specific about which pain is worse (back or leg)
• Back-dominant pain is anything above gluteal fold
• Mandatory to check for UMN signs (e.g. clonus, upgoing Babinski)
• Prone Extension Test
  • Patient is prone and asked to use their arms to elevate upper body until elbows lock and concentrate on letting lower back sag
  • Activity can be modified by placing hands further forward to reduce back extension
  • Repeated slowly
  • Prone Extension Positive (PEP) = Decrease or complete abolition of pain
  • Prone Extension Negative (PEN) = No relief with extension
  • Can help guide mobility exercises with physio

Diagnosis

• Lab testing
  • Indicated if concern for infection, tumor or rheumatological causes
  • ESR typically >20 (even if immunocompromised) if infectious aetiology
    • Sensitivity 90-98%
  • WCC not very sensitive or specific
  • CRP also elevated in acute spinal infection
  • Urinalysis if UTI or renal disease considered

Imaging

• RANZCR Guideline for acute low back pain imaging
  • Immediate imaging
    • MRI
      • Major risk factors for cancer (history of cancer)
      • Risk factors for spinal infection
        • Fever
        • Hx of IVDU, recent infection, recent invasive procedure
        • Elevated WCC/CRP
        • High clinical suspicion in at risk patient
      • Risk factors or signs of cauda equina
        • New urinary retention
        • Faecal incontinence
        • Saddle anaesthesia
      • Severe neurological deficit
        • Progressive motor weakness
        • Motor defects at multiple neurologic levels
    • Deferred imaging after trial of therapy
      • MRI
        • Weaker risk factors for cancer
          • Unexplained weight loss
          • Age >50 yrs
          • ESR >100
          • Hct <30%
        • Risk factors or signs of ankylosing spondylitis
          • Morning stiffness that improves with exercise
          • Alternating buttock pain
          • Waking from back pain in second part of night
          • Younger age (20-40)
        • Risk factors or symptoms of spinal stenosis if candidate for surgery
          • Radiating leg pain
          • Older age
          • Pseudoclaudication
        • Signs and symptoms of radiculopathy
          • Back pain with leg pain in L4, L5 or S1 distribution
          • Positive SLR or crossed SLR
      • Plain radiography
        • Risk factors for vertebral fracture
          • Steroid use
          • Significant trauma
          • Older age (>70)
          • Female
        • If negative plain XR and persistent clinical suspicion then MRI
  • No imaging
    • None of above and back pain improves or resolves after 1 month trial of therapy
    • Previous spinal imaging with no change in clinical status

Acute non-specific back pain

• Clinical diagnosis
• Mild to moderate pain, worse with movement, relieved by rest
• No risk factors on hx or exam or if risk factors present, diagnostic evaluation is unremarkable
• Treatment
  • Limit activities that worsen pain, regular analgesia, physio
  • 80-90% of patients will have resolution within 4-6 weeks
  • DeAlwis states 60-70% recover within 6 weeks (even if radiculopathy) and 80-90% by 12 weeks
  • Watchful waiting with further Ix at 6 weeks saves time and money with avoidance of unnecessary radiation exposure
  • Those who resume normal activities to the furthest extent tolerable recover more rapidly than bed rest or those who perform back mobilisation exercises
    • Improves pain and functional status by 3-4 weeks
  • Withold exercise programs until substantial improvement is seen
• Analgesia
  • Paracetamol as good as NSAID’s but combination may be better
  • Ibuprofen least toxic NSAID
  • Lowest dose possible of NSAID
  • Add PPI if at risk of GI bleeding (omeprazole 20mg daily)
  • Opioids should be offered for moderate to severe pain but for only 1 week as only effective in short-term
  • Diazepam = NSAID but no added benefit if used in combination
  • Corticosteroids have no role
  • Manipulation no better than standard conservative therapy (Cochrane)
  • Heat may be better than ice and provide some symptom relief
  • No evidence for any other therapy

Chronic non-specific back pain

• Best approach is review previous diagnostic approaches for completeness
• If complete and negative, treat as for acute non-specific back pain, otherwise complete it in ED or in a timely fashion as dictated by symptoms
• Benefits of medication are very small in this group
• Avoid opioids

Low back pain with sciatica

• Present in only 1% of back pain presentations
• Present in majority of those with symptomatic herniated discs
• Disc herniation is most common cause but anything that impinges or compresses the spinal nerve roots, cauda equina or spinal cord can cause this
• Consider intraspinal tumor or infection, foraminal stenosis, extraspinal plexus compression, piriformis syndrome and lumbar canal spinal stenosis
• Symptoms resolve for 90% with conservative treatment
• Surgery seems to make no discernable difference to long-term outcomes but may be considered if progressive unilateral neurological impairment or confirmed compression for >6 weeks
• Activity vs. bed rest makes no difference (as per DeAlwis)

Disc herniation

• Clinical diagnosis confirmed by non-urgent MRI
• Patients with sciatica generally c/o radicular pain > back pain
• 95% occur L4/5 (L5 nerve root)or L5/S1 (S1 nerve root)
• Small proportion (elderly mostly) have hernation at L2/3 (L3 root) or L3/4 (L4 root)
• Exam typically has neuro deficit in specific nerve root (L5 or S1 usually) with positive SLR
• If no red flags, treat conservatively and do not image in ED
• If demonstrable neuro deficit, plain X-ray can rule out some alternative causes such as tumor, fracture, spondylolisthesis and infection
• Non-urgent outpatient MRI can confirm diagnosis and rule out serious causes
• Emergent MRI recommended for severe or rapidly progressive deficits and those at risk of serious underlying cause
• Treatment
  • Treat as for non-specific back pain
  • NSAID’s are less effective for disc herniation than for non-specific back pain
  • Steroids have limited benefit
    • Epidural corticosteroid injection has limited minor reduction in leg pain and sensory deficits but no functional benefit and does not reduce need for surgery
    • It would be rare that this would be offered in the ED unless refractory to usual analgesia, confirmed disc on imaging and spinal team involved
    • Oral steroids have little measurable benefit
  • Heat or ice can provide temporary relief
  • Most patients improve over time, with >50% recovering within 6 weeks
  • Surgery is appropriate if all three criteria met:
    • Definitive evidence on imaging
    • Corresponding clinical picture and neurological deficit
    • Conservative treatment for 4-6 weeks has failed to produce improvement
• Emergency decompressive surgery
  • Only for acute epidural compression syndromes

Spinal stenosis

• Narrowing of spinal canal, nerve root canal or intervertebral foramina at single or multiple levels
• Degenerative disease leads to narrowing
• Can cause chronic back pain with/without sciatica
• Symptoms typically arise in 6^th decade with lower back pain aggravated by standing and spinal extension, relieved by rest and leaning forwards
• Typically present with lower back pain and lower limb pain while walking similar to vascular claudication (pseudo- or neuroclaudication)
  • Vascular claudication not altered by spinal flexion/extension
  • Neurogenic claudication does NOT get better if just stop walking unless sit down/lie down
• Examination usually normal
• Diagnosis is clinical and confirmed by CT or MRI
• Treat as for chronic back pain and get GP follow-up for confirmatory imaging unless symptoms/signs of epidural compression syndrome

Ankylosing spondylitis

• HLA-B27 associated autoimmune arthritis of the spine and pelvis
• Mostly men under 40
• Wake up lower back pain and stiffness that improves through day and with mild activity
• Symptoms >3 months and confirmed by imaging and labs
• X-ray shows sacroiliitis and squaring of vertebral bodies (bamboo spine)
• NSAID’s and referral to rheumatology for ongoing management

Epidural compression syndrome

• Collective term encompassing spinal cord compression, cauda equina syndrome and conus medullaris syndrome
• Possible causes include disc herniation, spinal canal haematoma, tumors of spine or epidural space and spinal canal infections (spinal epidural abscess)
• Transverse myelitis is a non-compressive condition that presents similarly
• Hx usually includes perianal pinprick sensory loss, incontinence with/without retention, sexual dysfunction and sciatica in one or both legs
• Urinary retention >500mL alone or in combination with two of the following are the most important predictors of cauda equina:
  • Bilateral sciatica or crossed positive SLR
  • Subjective urinary retention
  • Rectal incontinence symptoms
• Angus et al. retrospectively analysed ~1000 patients with suspected cauda equina syndrome and found the following to be most predictive:
  • Bilateral leg pain (OR 2.2)
  • Dermatomal sensory loss (OR 1.8)
  • Bilateral absent ankle or knee jerks (OR 2.9)
  • No relationship between PR examination findings and confirmed CES
• Urinary post-void residual >200mL is 97% sensitive for cauda equina (Venkatesan et al.)
• Korse et al. showed sciatica was unilateral in 60%
• Hx of malignancy and rapid progression of neurological symptoms increases the likelihood also
• Most common examination finding is urinary retention +- overflow incontinence
  • Sensitivity 90% and specificity 95%
• Saddle anaesthesia is the most common sensory deficit
• Anal sphincter tone is reduced in 60-80% of cases
• If one suspects epidural compression, especially if due to tumor, give IV dexamethasone 10mg, before confirmatory imaging
• Emergent MRI warranted for all suspected cases (entire spine if suspected neoplasm as 10% will have vertebral metastases missed by local imaging only)
  • If pure cauda equina syndrome from herniated disc is suspected, localised MRI is reasonable
• Functional outcome
  • Depends on symptoms on presentation
  • If cannot walk before treatment, rarely can afterwards
  • If too weak to walk without assistant but not paraplegic – 50% chance of walking again
  • If able to walk, likely to remain ambulatory
  • Of those who require a catheter before treatment, 82% will require ongoing catheterisation
• 3 classical patterns described
  • Type 1 – Acutely as first symptom of lumbar disc herniation
  • Type 2 – Endpoint of chronic back pain with/without sciatica
  • Type 3 – Insidiously onset with slow progression to numbness and urinary symptoms
• 2 clinical categories in practice
  • Cauda equina with urinary retention
  • Incomplete cauda equina with reduced urinary sensation, loss of desire to void, or poor stream, but no established retention or overflow
• Clinical diagnosis of cauda equina syndrome by Consultant Neurosurgeons has a 43% false positive rate
• How urgent is surgery?
  • Ahn et al. showed better sensory, motor, urinary and rectal function if decompression were performed within 48 hours

Conus medullaris syndrome

• T12 to L2 lesions
• Conus medullaris lies close to lumbar nerve roots so often get mixed upper and lower motor neuron signs (as opposed to cauda equina LMN)
• Can result from lumbar stenosis due to intervertebral disc herniation) or trauma with spondylolysis or spondylolisthesis
• Presents similarly to cauda equina except mixed UMN and LMN
• 10% of patients regain functional recovery

Transverse myelitis

• Compression transverse section of spinal cord inflammation
• Usually neck or back pain with neurological complaints and signs
• Typically bilateral motor, sensory and autonomic disturbance over days to weeks
• Faecal and urinary retention/incontinence are common
• May be due to viral infection, post-vaccination, SLE, cancer or multiple sclerosis (more common)
• Viruses: EBV, CMV, Mycoplasma, Enterovirus, Adenovirus
• Manage as for epidural compression syndrome as presents the same
• MRI may lag the clinical findings (especially early)
• If definite neuro findings but normal MRI, admit neuro and get LP – lymphocytosis and elevated protein
• Treatment is steroids and plasma exchange

Spinal infection

• Includes vertebral osteomyelitis, discitis and spinal epidural abscess
• Commonly missed on first assessment
• Mostly thoracic
• MRI is investigation of choice but if not available, CT will show advanced disease or larger abscesses requiring drainage
• Risk factors include immunocompromise, alcoholism, recent invasive procedure, spinal implants/devices, IVDU and skin abscesses
• Vertebral osteomyelitis
  • Prolonged symptoms (often >3 months)
  • 50% have fever and vertebral body tenderness
  • WCC may be normal but CRP and ESR almost always elevated
  • BC positive in 50% of cases and should be routinely drawn if suspected
  • Plain X-ray normal for 2-8 weeks until demineralisation begins
  • Most common X-ray findings are bony destruction, irregularity of vertebral body endplates and disc space narrowing
• Discitis
  • >90% present with unremitting back or neck pain, waking them at night and not relieved by rest or analgesics
  • Fever in 60-70% of patients
  • Neuro deficits in only 10-50%
  • ESR elevated in >90% of patients
  • WCC elevated in <50%
• Spinal epidural abscess
  • Classic triad of severe back pain, fever and neurological deficit (seen in only 8-13% of patients)
  • Commonly found in associated with vertebral osteomyelitis and/or discitis
  • Risk factors 98% sensitive for epidural abscess include IVDU, immunocompromise, alcoholism, recent spinal procedure, distant site of infection, diabetes, indwelling catheter, recent spinal fracture, chronic renal failure and cancer
  • ESR elevated >20 in 95% of patients
  • Contrast-enhanced MRI is gold standard
• Treatment
  • Epidural abscess – Antibiotics and spinal surgeon involvement
  • Discitis – Long-term antibiotics with surgery for cord compression or biomechanical instability
  • Vertebral osteomyelitis – IV antibiotics for 6 weeks then 4-8 weeks of orals
    • Consult with spinal surgeon before antibiotics as may result in negative culture results from bone biopsy
  • Empirical Staph aureus cover

Metastatic spinal disease

• Metastatic spinal disease affects 30% of cancer patients
• Cord compression in 5%
• Lung, breast, prostate mostly
• Back pain precedes neurology by months in 95%
• Pain radicular in 80% of cases
• Motor > sensory
• Sensory may cover multiple dermatomes below level of lesion
• Plain film 85% sensitive; MRI 95% sensitive and specific (even better with gadolinium)
• Glucocorticoids 10mg IV dexamethasone bolus if signs of cord compression then 4-10mg QID dex
• Radiotherapy
  • Within 24 hours of cord compression if previously ambulant
  • Provides pain relief even if neurology remains unchanged
  • Highly responsive to radiotherapy
    • Lymphoma, myeloma, seminoma
  • Intermediate
    • Breast, ovarian, prostate
  • Poorly response
    • Non-small cell
    • Renal, thyroid, GI, sarcoma, melanoma
• Chemotherapy
  • Lymphoma, MM, small cell lung cancer
• Surgery
  • Spinal instability or poor response to above

Last Updated on July 13, 2023 by Andrew Crofton