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8/17/2019 Assessment and Diagnosis of Spinal Pain 2015
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Spinal Pain
Assessment andDiagnosis
Sanjeeva GuptaMD; DNB; FRCA; FIPP; FFPMRCA
Consultant in Pain Medicine
Bradord !eac"ing #ospitals N#S
!rust
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Spinal PainAssessment and Diagnosis
• Pain in Cervical$ lum%ar and SI&
• #istor' –
Red Flags – Cauda ()uina
• Clinical (*amination
•
Investigations• Diagnosis
• Management
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#istor'
• Age and gender o t"e patient
• #o+ did t"e spinal pain start,
•
#istor' o !rauma or road tra-caccident
• Aggravating and relieving actors
•
C"aracter o pain . nociceptiveand/or neuropat"ic pain
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#istor'
• Famil' "istor' o spinal pain and in0ammator'conditions
• Famil' "istor' o inective diseases li1e
tu%erculosis• Previous and current treatment or spinal pain
• #istor' o co2mor%idities3 respirator'$ cardiac$central nervous s'stem$ gastrointestinal$
renal$ "epatic$ etc$ as can in0uence c"oice op"armacot"erap'
• Drug allergies
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#istor' 2 Red Flags
#istor'•
•Previous "istor' malignanc'
•Age 456 or 478 +it" N(9 onsetpain
•9eig"t loss :une*plained
•Previous longstanding steroid use•Recent serious illness
•Recent signi<cant inection
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#istor' 2 Red Flags
S'mptoms• Non2mec"anical pain :+orse at
rest• !"oracic pain
• Fevers/ rigors
•
General malaise• =rinar' retention
• Faecal incontinence
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Red Flags :(*amination
Signs
• Saddle anaest"esia
•
>oss o anal tone• Multilevel sensor'2motor
de<cits
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Cauda ()uina
S'mptoms• =rinar' retention
•
Faecal incontinence
Signs
• Saddle anaest"esia
• >oss o anal tone
• Multilevel sensor'2motor de<cits
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#istor'
• Medications
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(*amination
• Neurological e*amination
• Rule out red 0ags
• An' neurological signs to con<rm radicular/neuropat"ic pain,
• Midline pain in 'ounger patients$ +orse on0e*ion ma' %e discogenic pain
• Paraspinal pain +orse on lum%ar spinee*tension and rotation ma' %e o acet joint
origin• >o+er %ac1 pain in a multiparous emale
patient$ most severe %elo+ >7 spinal level ismore li1el' to %e sacroiliac joint mediated
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Investigations
•
Blood tests or in0ammator' mar1ers• Role o ?2Ra' is limited$ unless "istor' o
trauma
• C! Scan "elpul +"en %one relatedcauses are suspected
• Role o =ltrasound is limited unless torule out ot"er a%dominal causes o >BP
• MRI scan is "elpul +"en planninginjection t"erap' or surger' to de<ne t"etarget level
• Nerve conduction studies
• Precision Dia nostic in ections /
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Diagnosis
• Pain rom
–Facet joints
–Discs
–Sacroiliac &oints
–Muscles
–>igaments
–A%dominal organs
–Pelvic @rgans
–!"oracic organs
• Predominant radicular pain ie sciatica
• In0ammator' conditions ie R"eumatoidArt"ritis$ An1'losing spond'litis
•>o+ Bac1 Pain . not a diagnosis %ut a condition
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Management
• Advice/sel management
• P"armacot"erap'
• Consider and treat neuropat"ic pain
• Complementar' t"erap'
• P"'sical t"erap'
• Reerral to specialist centre i pain
is not improving or t"e patient "asradicular pain not improving +it"p"armacot"erap'
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Role o Famil' P"'sician
• Rule out red 0ags
• Reassure and educate patients +"opresent +it" acute lo+ %ac1 pain as oten
t"e pain is li1el' to settle +it"conservative management
• !reat pain aggressivel' to preventc"ronicit' ie re)uent ollo+ up to revie+progress
• I pain not getting %etter reassess in t+o+ee1s o initial presentation
• (arl' reerral to p"'sical t"erap'
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Role o Famil' P"'sician
• Advice regarding "ealt"' living$ smo1ingcessation as evidence suggest pooroutcome and recover' in smo1ers
•
Identi' i patient "as radicular pain astreatment is dierent
• (*plain to t"e patient t"e cause o pain andits management$ s"ared decision ma1ing+ill "elp to develop a management plant"at %ot" t"e patient and clinician support
• Reer to specialist centre i pain notcontrolled
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Summar'
• Assessment – #istor'
– (*amination
– Investigations
• Diagnosis
• Management
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