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trauma clinic

What would you do with a patient still in pain following a fall?

Mr William Burgoyne offers some advice

Case history

A 27-year-old self-employed decorator fell 4ft from his ladder, sustaining a twisting injury to his lower lumbar spine. He developed acute severe low back pain. On examination he was in considerable discomfort and could only stand with difficulty. Prone, palpation of his lumbar spine revealed bilateral para-vertebral spasm and diffuse tenderness between L2 and L5. Neurological examination of his lower limbs was unremarkable, as were radiographs of his lumbar spine. He was given anti-inflammatory and analgesic medication. Over the next

48 hours, although his back pain eased, he developed increasingly severe right anterior thigh pain, and sought further advice from his GP.

Analysis

Severe back pain following trauma is likely to be mechanical in origin. However it is important to exclude any pre-existing 'red flag' symptoms or signs that may suggest a more significant underlying cause:

•Presentation < 20="" or=""> 55 years

•Non-mechanical pain

•Thoracic pain

•Past history - carcinoma, steroids, HIV

•Unwell, weight loss

•Widespread neurological symptoms or signs

•Structural deformity

Back pain following injury can arise from a number of causes. Although the intervertebral disc is commonly implicated, it is difficult to identify a specific pain pattern that distinguishes one source of back pain from another. In this case the absence of 'red flag' symptoms, the lack of osteoporosis risk factors and relatively low energy trauma made significant bone injury unlikely; benign avulsion fractures of the transverse processes are however sometimes seen. As a result plain radiographs of the lumbar spine were unlikely to reveal a specific treatable cause.

Diagnostically, it is useful to try and distinguish between referred and root (radicular) pain.

•Referred back pain from degenerative change or an acute structural injury is often poorly localised and can appear in the buttock and posterior thigh down as far as, but rarely below, the knee. This has given rise to the description of 'thermometer pain' – the worse the pain the lower it creeps. Referred pain may also manifest itself just behind the greater trochanter of the femur. Patients may then complain of 'hip' pain rather than back pain. Referred pain is a manifestation of mechanical back pain where symptoms are exacerbated by activity, eased by rest, and are of variable intensity on a day-to-day basis. Initially this was the diagnosis in the case described above.

•Root or radicular pain is dermatomal in distribution, and may be accompanied by motor weakness or loss of reflexes. Anterior thigh pain, if arising from the spine, is usually from the L3 or L4 nerve roots. L5 nerve root pain usually appears over the dorsum and medial aspect of the foot. S1 root pain normally presents over the lateral side or the sole of the foot, but equally may be confined to the back of the thigh, making a distinction between referred and radicular pain difficult! However, weakness of ankle dorsiflexion (L4), great toe flexion (L5), or an absent ankle reflex (S1) with an appropriate sensory disturbance would support a diagnosis of radicular pain.

Diagnosis

The thigh pain suggested a possible right-sided L3 or L4 radiculopathy; preceded as it was by severe back pain, it was likely that this was the result of a disc herniation at L2/3 or L3/4. MRI is the investigation of choice in any patient with suspected lumbar radiculopathy with no response to non-operative or conservative measures for six weeks or more. However, patients with severe unremitting pain or red flag symptoms should have referral or an MRI expedited, as occurred in this case (see left).

This revealed two possible causes for his pain. At the L3/4 level a significant right-sided disc herniation can be seen impinging on the traversing L4 nerve root. At L4/5 an annular tear, which appears as a bright white line in contrast to the dark signal from the disc, is apparent. Either can cause mechanical irritation by stretching free nerve endings in the outer margin of the annulus fibrosis.

In addition, certain cytokines identified within herniated disc material may have a direct nociceptive effect on these nerve fibres. Nerve compression may result in loss of function (weakness or numbness), but is not normally thought to produce pain. This results from the inflammatory response following mechanical or chemical irritation of the nerve. Annular tears may produce radicular symptoms without the compression seen in disc herniation. A steroid epidural may provide relief through anti-inflammatory action. But the pain may return if there is subsequent disc resorption or satisfactory tear healing.

Treatment

There is evidence that positive reinforcement and the attitude of the doctor can improve both treatment results for back pain and patient satisfaction with care. Regardless of treatment, 90 per cent of back pain, with or without radicular symptoms, will improve within six weeks. Therefore it is reasonable to pursue an expectant management approach which should be directed towards symptom relief and providing reassurance. Short-term use of anti-inflammatory, analgesic medication and muscle relaxants can allow an early return to everyday activities. Patients not improving by six weeks may benefit from an active rehabilitation programme such as a back-to-fitness programme. Manipulative therapy can also be effective in the treatment of acute low back pain. In the patient described, an epidural provided marked relief of symptoms within 72 hours. He was then referred for physiotherapy, and has had minimal residual symptoms since.

William Burgoyne is consultant spinal surgeon at Epsom General Hospital

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