Acute back pain/osteoporosis

Question 1

List five red flags for lower back pain

Answer 1

duration >6 weeks
weight loss
incontinence
bowel function
saddle anaesthesia 
pain worsened by coughing, sitting, or valsalva maneouvre, any neurological defect, age <18y >50y, cancer hx 
fever
nocturnal pain
fever, night sweats

Question 2

Yellow flags for back pain?

Answer 2

social withdrawal, emotional problems, lack of support/overprotective family, belief that pain and activity are harmful

Question 3

Four differentials for lower back pain?

Answer 3

Non-specific: muscle spasm, muscle sprain/strain, ligamentous injury

Vertebral compression fracture

Metastatic cancer

Cauda equina syndrome

Infections

Sciatica

Ankylosing spondylitis

Question 4

Name five risk factors for osteoporosis

Answer 4

1. early menopause
2. smoking hx
3. alcohol hx
4. steroid use
5. parent with hip fracture
6. obesity
7. female
8. LOW BMI

Question 5

How is osteoporosis formally diagnosed?

Answer 5

DXA scanning, T score <-2.5

Question 6

What is the management of osteoporosis?

Answer 6

1. Resistance training
2. Lifestyle modification- smoking cessation, reducing alcohol
3. Oral calcium
4. Oral vitamin D
5. Biphosphonate therapy

Question 7

Acronym for surgical history (routine questions)

Answer 7

AMPLE
allergies
medications
PMH
last eaten or drank
events leading to presentation

Question 8

What are the components of a myeloma screen?

Answer 8

LDH, calcium/bone profile, ESR, urine bence jones protein, immunoglobulins and protein electrophoresis

Question 9

What is the MOA of biphosphonates?

Answer 9

antiresorptive- bind to bone surface, once absorbed by osteoclasts, they activate apoptosis and result in cellular death of osteoclasts. Reduced bone loss but do not add new bone

Question 10

Name a biphosphonate typical prescribed

Answer 10

alendronic acid

Question 11

How would you advise a patient to administer their biphosphonate?

Answer 11

• once per week
• take first thing in the morning before food and other meds.
• Drink plenty of water and sit upright for 30 mins and don’t eat or drink anything in this time. -Wait at least 4 hours before taking calcium/vit D supplement

Question 12

Name three side effects of biphosphonates

Answer 12

nausea, osteonecrosis of jaw, oesophageal ulceration, heartburn/indigestion, headache, tiredness

Question 13

Why should you not take calcium with alendronic acid?

Answer 13

calcium inactivates it

Question 14

What would be an alternative biphosphonate to alendronic acid?

Answer 14

zolendronic acid, give as IV infusion once yearly!!

Question 15

Which conditions are associated with osteoporosis?

Answer 15

T1D
osteogenesis imperfects
hyperthyroidism/hyperparathyroidism, chronic malnutrition, malabsorption e.g. crohn’s disease, chronic liver disease

Question 16

What are the causes of fragility fractures?

Answer 16

osteoporosis and osteopenia

Question 17

Name three of the most common bone fractures relating to osteoporosis

Answer 17

1. Femoral neck fracture
2. Vertebral fracture
3. Distal radius fracture

Question 18

Three differentials for back pain

Answer 18

Mechanical 
  Strain/idiopathic 
  Trauma 
  Pregnancy  
  Disc prolapse 
  Spondylolisthesis (forward shift of one vertebra) 

Degenerative: spondylosis, vertebral collapse, stenosis

Inflammatory: Ank spond, Paget’s

Neoplasm: Mets, myeloma

Infection: TB, abscess

Question 19

Three conservative options for back pain?

Answer 19

Physical activity
Advice on stooping, handling
Physio
Pyschosocial

Question 20

Two examples of neurosurgical emergencies associated with back pain

Answer 20

Acute cord compression

Acute cauda equina compression

Question 21

Two signs/symptoms of acute cord compression?

Answer 21

 Bilateral pain: back and radicular
 LMN signs at compression level
 UMN signs and sensory level below compression
 Sphincter disturbance

Question 22

Two signs/symptoms of cauda equina?

Answer 22

 Alternating or bilateral radicular pain in the legs
 Saddle anaesthesia
 Loss of anal tone
 Bladder ± bowel incontinence

Question 23

Two causes of acute cord compression and cauda equina syndrome

Answer 23

prolapse
tumours
abscess

Question 24

Define osteoporosis

Answer 24

a skeletal condition characterized by decreased density (mass/volume) of normally mineralized bone. This leads to decreased mechanical strength, thus making the skeleton more likely to fracture.

Question 25

Four risk factors for osteoporosis?

Answer 25

``` SHATTERED  Steroids  Hyperthyroidism, HPT, HIV  Alcohol and Cigarettes  Thin (BMI <22)  Testosterone Low  Early Menopause  Renal / liver failure  Erosive / inflam bone disease (e.g. RA, myeloma)  Dietary Ca low / malabsorption ```

Question 26

Which is the gold standard test in osteoporosis?

Answer 26

DEXA scan

Question 27

Two indications to perform DEXA scan?

Answer 27

 Low-trauma #  Women ≥65yrs c¯ one or more risk factors  Before giving long-term steroids (>3mo)  Parathyroid disorders, myeloma, HIV

Question 28

DEXA result T=1. What does this imply?

Answer 28

bone density normal

Question 29

DEXA result T= -2. What does this imply?

Answer 29

osteopenia T -1 - -2.5

Question 30

DEXA result T= -3. What does this imply?

Answer 30

osteoporosis

Question 31

What is a FRAX score?

Answer 31

estimates the probability of a fracture within the next 10 years

Question 32

Two conservative options for managing osteoporosis?

Answer 32

stop smoking drink less alcohol Ca and Vit D rich diet visual assessment- prevention of falling (+mobility aids?)

Question 33

What is the first line treatment for osteoporosis?

Answer 33

Biphosphonate- alendronate

Question 34

MOA of biphosphonates?

Answer 34

inhibit osteoclastic bone resorption

Question 35

Two SE of biphosphonates?

Answer 35

 GI upset  Oesophageal ulceration / erosion- Take plenty of water on an empty stomach and refrain from lying and don’t eat for 30min.  Diffuse musculoskeletal pain  Osteonecrosis of the jaw

Question 36

Name two biphophonates

Answer 36

alendroate/alendronic acid and zoledronic acid

Question 37

Name one other drug indicated in osteoporosis and provide its MOA

Answer 37

Teriparetide: PTH analogue → new bone formation Denosumab: anti-RANKL → ↓ osteoclast activation

Question 38

List three lifestyle factor changes that promote bone health?

Answer 38

weight bearing exercise smoking cessation excessive alcohol cessation

Question 39

Which co-existing diagnosis often exists alongside osteoporosis? Name a blood test that would confirm this diagnosis

Answer 39

Osteomalacia | 25-hydroxyvitamin D level