OR6.1 | Degenerative Low Back and Neck Pain — Summary & Reflection

KEY TAKEAWAYS

Degenerative Low Back and Neck Pain — Summary

Causes of low back pain span seven major categories: degenerative (spondylosis, PID, stenosis, spondylolisthesis), inflammatory (ankylosing spondylitis), infective (pyogenic discitis, Pott's disease), neoplastic (metastases, myeloma), metabolic (osteoporotic fracture), referred (AAA, renal/pelvic pathology), and mechanical (muscular strain, facet arthropathy). Red-flag causes (tumour, infection, neurological compromise, ankylosing spondylitis = TUNA) require immediate investigation.

Pathology: Disc degeneration — desiccation, height loss, annular tears — produces secondary facet arthritis and canal/foraminal encroachment. In the cervical spine this causes radiculopathy (foraminal osteophyte → root compression) or myelopathy (central canal stenosis → cord compression). In the lumbar spine: radiculopathy from disc herniation, or neurogenic claudication from canal stenosis.

PID dermatomal localisation: L4/L5 disc → L5 root (dorsum foot, EHL weakness, no reflex lost); L5/S1 disc → S1 root (lateral foot, plantar flexion weakness, absent ankle jerk). SLR positive <70° = radiculopathy.

Cauda equina syndrome (RED FLAGS — surgical emergency): saddle anaesthesia + bladder/bowel dysfunction + bilateral leg weakness/sciatica. Emergency MRI → decompression within 24-48 h.

Management: Conservative (NSAIDs, physiotherapy, ± epidural steroid) for 6-12 weeks in non-emergency cases. Surgery for: myelopathy (any grade), failed conservative treatment, progressive neurological deficit. Procedures: ACDF/laminoplasty (cervical); microdiscectomy/laminectomy/fusion (lumbar).

REFLECT

Think about a patient you have encountered (or one described in a case report or clinical teaching session) with back or neck pain who turned out to have something more serious than initially thought — perhaps a missed metastatic deposit, an undiagnosed myelopathy, or delayed cauda equina decompression.

Reflect on these questions:
1. What clinical features, if any, were present at the initial presentation that, in retrospect, should have triggered earlier investigation?
2. Which element of the OR6.1 competency (enumeration of causes / clinical features / investigations / management principles) do you find hardest to apply in real clinical decision-making, and why?
3. How will you systematically screen every back-pain patient for the five cauda equina red flags in your future practice?

Write a brief paragraph (5-8 sentences) reflecting on one specific change you will make to your clinical history-taking or examination routine as a result of working through this module.