Regarding a patient presenting with acute lumbosacral pain without sciatica, which ONE of the following statements is TRUE?
Answer: C: Acute lumbosacral pain (acute low back pain) is normally referred to as low back pain that is confined to the lumbosacral region and is not associated with radicular pain (sciatica). Most patients have no identifiable abnormailites, even with radiological imaging. Therefore imaging of these patients is unlikely to be helpful unless red flag features are present. The causes include:
About 60–70% of these patients, even with radicular symptoms, recover within 6 weeks and 80–90% recover by 12 weeks. If the symptoms persist for more than 12 weeks, the recovery will be unpredictable and slow.
The advice to stay active rather than to have bed rest has been found to improve the pain at 3–4 weeks as well as functional status.
Reference:
Regarding sciatica, which ONE of the following statements is TRUE?
Answer: D: In sciatica the pain is mainly localized to the leg and is due to stimulation of the nerve roots or dorsal root ganglion. Therefore it is a radicular pain. This radicular pain can be associated with a radiculopathy, that is, symptoms of numbness, weakness and loss of deep tendon reflexes corresponding to a specific nerve root. Causes of acute radicular pain include:
In most patients without progressive neurological deficits such as worsening weakness and numbness, bladder or bowel dysfunction, the initial treatment should be symptomatic. ‘Red flag’ features should be excluded in the history and physical examination. CT and/or MRI imaging are not indicated for acute sciatica if the above features are not present.
Symptoms usually resolve in 90% of patients without specific treatment. Most patients with HNP do not require surgical intervention to control pain.
When persistent radicular pain is present, it is important to look for reversible causes. Staying active versus bed rest has not been shown to make any difference to the pain or functional outcome in sciatica.
Sciatica is essentially a neuropathic pain. Tricyclic anti-depressents and selective noradrenaline reuptake inhibitors (e.g. venlafaxine) and antiepileptics (e.g. gabapentin) have been shown to be effective in the management of other common forms of neuropathic pain. These medications can be tried in patients with persistent symptoms of sciatica.
A 70-year-old female presents to the ED with acute low back pain. The report of a CT lumbar spine ordered by the general practitioner (GP) states that there is moderate to severe lumbar spinal canal stenosis with degenerative changes of the lumbar vertebrae. On examination, there is no neurological deficit.
Regarding lumbar spinal canal stenosis, all of the following statements are true EXCEPT:
Answer: C: Lumbar spinal canal stenosis is a relatively common condition causing low back pain secondary to compression on lumbar spinal nerve roots. The elderly often present to the ED with disabling low back pain due to this condition. The most common symptom complex caused by lumbar spinal canal stenosis is called neurogenic claudication. The symptoms are mechanical low back pain radiating to the buttocks and thighs, or often to the entire leg. The pain typically gets worse on walking and standing and subsides or resolves with sitting, flexion of the lumbar spine or lying. Unlike in vascular claudication due to peripheral vascular disease, the pain does not resolve when the patient stops walking. Symptoms are bilateral and often asymmetrical in the majority of cases. Lower limb weakness occurs in less than half of these patients. Associated cauda equina syndrome and lumbosacral radiculopathy are uncommon in this condition.
In lumbar spinal canal stenosis the narrowing may occur either in the central canal, the area under the facet joints or at the neural foramina. The causes of spinal canal stenosis in the elderly are mainly degenerative and they include:
Other causes include post-laminectomy and post-fusion surgeries.
ED management includes analgesia and orthopaediac referral for outpatient follow-up or admission for patients with disabling symptoms.
References:
A 40-year-old man presents to the ED with a history of a penetrating injury to the palmar surface of the middle phalanx of the left middle finger. The injury happened 2 weeks ago when he was using a cordless drill during a DIY job at home. For the past 3 days his finger has become swollen and painful. There is a limited range of movement at the proximal (PIP) and distal interphalangeal (DIP) joints due to severe pain.
Regarding assessment and management of this patient, which ONE of the following statements is TRUE?
Answer: D: Although septic arthritis of interphalangeal joints cannot be excluded in this patient, it is more likely that this patient has flexor tendon sheath infection (infectious flexor tenosynovitis) secondary to direct inoculation of the organisms during the injury. The most common organism involved is Staphylococcus aureus followed by Streptococcus species; both are native skin flora.
The presence of four Kanavel signs clinically confirms infectious flexor tenosynovitis:
Flexor tendon sheaths of the thumb and the little finger extend into the carpal tunnel and the infection in these sheaths can easily spread to the carpal tunnel and forearm. The proximal ends of the flexor tendon sheaths of the index, middle and ring fingers overlie the midpalmar space and therefore the infection can extend to the midpalmar space.
If the patient presents within the first 24 hours from infection onset, and especially if the extent of the nfection is mild, conservative treatment with in-hospital intravenous antibiotics can be tried. However, if there is no significant improvement with this treatment in 24 hours surgical drainage is indicated without further delay. If the injury is more than 48 hours old, conservative management is likely to fail and urgent surgical drainage is advised to achieve the best functional outcome. Complications associated with delayed diagnosis and treatment are flexor tendon necrosis and digital contracture.
Regarding likely infecting organisms involved in causing acute osteomyelitis in adults, all of the following statements are true EXCEPT:
Answer: D: In adults, acute osteomyelitis arises from direct inoculation of the organisms following injury or surgery or due to spread from the contiguous structure such as a joint. In children haematogenous spread is more common. In adults the site most commonly involved is the spine, whereas in children long bones are most commonly involved. Overall, Staphylococcus aureus, both methicillin sensitive (MSSA) and methicillin-resistant (MRSA – both non-multiresistant and multiresistant) is the most commonly implicated organism. In the elderly the most common organism causing osteomyelitis is Staphylococcus aureus; however, enteric gramnegative organisms are commonly involved in oeteomyelitis affecting the spine.
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