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

8/17/2019 Assessment and Diagnosis of Spinal Pain 2015

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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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