Back Pain

Question 1

What are the functions of the spine (3)?

Answer 1

• Locomotor: capable of being both rigid & mobile
• Bony armour: protects the spinal cord
• Neurological: spinal cord transmission of signals between brain & periphery

Question 2

How many vertebrae does the spinal column consist of?

24 bones

Answer 2

• 7 cervical
• 12 thoracic
• 5 lumbar

Question 3

What is the function of the intervertebral discs of the spinal column (2)?

Answer 3

• Shock absorbers
• Allow segmentation & multi-directional movement

Question 4

What are the facet joints of the spinal column?

Answer 4

• Small synovial joints at posterior spinal column linking each vertebra

Question 5

What is the function of the muscles of the spinal column?

Answer 5

• Move the spine

Question 6

Where does the spinal cord end?

Answer 6

L2

Question 7

What is found after the spinal cord?

Answer 7

Cauda equina

Cauda equina: nerve bundle

Question 8

What are the movements of the spinal cord (4)?

Answer 8

• Flexion (forward bend) vs extension (backward bend)
• Lateral flexion (side bend)
• Rotation (twist)

Question 9

Outline the epidemiology of back pain?

Common
Effect
When does it get better

Answer 9

• Very common: > 50% of people will experience an episode
• Acute back pain usually self-limiting
• Most better in a few days, 96% are better in six weeks

• Chronic back pain (>12 weeks duration) also common – sedentary lifestyle
• Need to distinguish mechanical back from serious pathology

Question 10

What are the causes of back pain differentiated into?

Answer 10

• Mechanical back
• Serious pathology

Question 11

What are the signs and symptoms of mechanical back pain?

When it comes to movement and rest

Answer 11

• Reproduced or worse with movement
• Better or not present at rest

Question 12

What are the common causes of mechanical back pain (4)?

Answer 12

• Muscular tension (e.g. chronic poor posture, weak muscles)
• Acute muscle sprain / spasm
• Degenerative disc disease
• Osteoarthritis of facet joints

Question 13

What symptom may is common with mechanical back pain?

Mechanical back pain caused by disc herniation

Answer 13

• Sciatica

Sciatica: pain radiating down one leg

Question 14

What determines the location of pain caused by sciatica?

Answer 14

• Level of the herniated disc

Question 15

What are the serious pathology causes of back pain (5)?

Answer 15

• Tumour
• Infection
• Inflammatory spondyloarthropathy
• Fracture (traumatic or atraumatic)
• Large disc prolapse causing neurological compromise

Referred pain (pancreas, kidneys, aortic aneurysm)

Question 16

What types of tumour can cause back pain (2)?

Answer 16

• Metastatic cancer
• Myeloma

Question 17

What serious infections can cause back pain (6)?

Answer 17

• Discitis
• Vertebral osteomyelitis
• Paraspinal abcess
• Microbiology:
  
  • Staphylococcus
  • Streptococcus
  • Tuberculosis (TB)

Question 18

What inflammatory spondyloarthropathy can cause back pain (3)?

Answer 18

• Ankylosing spondylitis
• Psoriatic arthritis
• Inflammatory bowel disease (IBD) - associated

Question 19

What are the “red flag” symptoms of back pain that may indicate serious pathology (10)?

Answer 19

• Pain at night or increased pain when supine
• Constant or progressive pain
• Thoracic pain
• Weight loss
• Previous malignancy
• Fever / night sweats
• Immunosuppressed
• Bladder or bowel disturbance (Sphincter dysfunction)
• Leg weakness or sensory loss
• Age < 20 or > 55 yrs

Question 20

What are the symptoms / signs of cauda equina syndrome (5)?

• Cauda equina syndrome is a neurosurgical emergency
  
  • Untreated = permanent lower limb paralysis and incontinence

Answer 20

• Saddle anaesthesia
• Bladder / bowel incontinence
• Loss of anal tone on PR
• Radicular leg pain
• Ankle jerks may be absent

Question 21

What investigation is required in suspected cauda equina syndrom?

• Cauda equina syndrome is a neurosurgical emergency
  
  • Untreated = permanent lower limb paralysis and incontinence

Answer 21

• Urgent MRI L spine

Question 22

What are the causes cauda equina syndrome (5)?

• Cauda equina syndrome is a neurosurgical emergency
  
  • Untreated = permanent lower limb paralysis and incontinence

Answer 22

• Large disc herniation
• Bony mets
• Myeloma
• TB
• Paraspinal abcess

Question 23

What is the treatment of cauda equina syndrome?

• Cauda equina syndrome is a neurosurgical emergency
  
  • Untreated = permanent lower limb paralysis and incontinence

Answer 23

• According to cause: may require urgent surgery

Question 24

What is the treatment for low back pain without red flags (4)?

Answer 24

• Time
• Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
• AVOID bed rest: keep moving
• Physiotherapy
  
  • Soft tissue work
  • Corrective exercises esp. core

Question 25

What investigations (blood test) are recommended for back pain (6)?

Answer 25

* Erythrocyte sedimentation rate (ESR) * C-reactive protein (CRP) * Full blood count (FBC) * Alkaline phosphatase (ALP) * Calcium * PSA (prostate specific antigen)

Question 26

When is erythrocyte sedimentation rate (ESR) abnormal in back pain?

Answer 26

Increased in: * Myeloma * Chronic inflammation * TB

Question 27

When is C-reactive protein (CRP) abnormal in back pain?

Answer 27

Increased in: * Infection * Inflammation

Question 28

When is alkaline phosphatase (ALP) abnormal in back pain?

Answer 28

Increase in: * Bony metastases (mets)

Question 29

When is calcium abnormal in back pain?

Answer 29

May be increased in: * Myeloma * Bony metastases (mets)

Question 30

When is full blood count (FBC) abnormal in back pain?

Answer 30

* Anaemia in: * Myeloma * Chronic disease * Increase in: * WCC in infection

Question 31

When is PSA (prostate specific antigen) abnormal in back pain?

Answer 31

Increased in: * Prostate cancer with bony mets

Question 32

What investigations (imaging) are recommended for back pain (3)?

Answer 32

* **Radiographs (X-rays):** * Poor sensitivity, radiation * Cheap, widely available * **Computed tomography (CT) scans:** * Good for bony pathology, larger radiation dose * **Magnetic resonance imaging (MRI):** * Best visualization of soft tissue structures like tendons and ligaments * Best for spinal imaging: can see spinal cord and exiting nerve roots * Expensive and time-consuming

Question 33

What is the diagnosis: * 70 year old woman * Acute onset thoracic spine pain with radiation through to the chest wall * Focally tender over thoracic spine

Answer 33

* **Osteoporotic vertebral collapse** * “Wedge fracture”

Question 34

What is the diagnosis: * 25 year old man originally from Nepal * Worsening low back pain for 8 weeks * Worse in the morning but present at all times * Weight loss * Night sweats

Answer 34

* **L4/5 endplate destruction** * Soft tissue mass encroaching spinal canal

Question 35

What is the diagnosis: * A 45-year-old man complains of acute back pain and sciatica extending down the R leg into the foot associated with paresthesia * No incontinence of bladder/bowel * Examination: no weakness, sensation intact * He has been off work for two weeks and wants to know when he can get back to work

Answer 35

Herniated discs

Question 36

How is a herniated disc managed (3)?

Answer 36

* **Conservative** as for LBP without sciatica * **Analgesia** especially NSAIDs * **Physiotherapy** to improve core strength and treat associated muscle spasm * **Nerve root injection** (local anaesthetic and glucocorticoid) * **Surgery** if neurological compromise or symptoms persist

Question 37

What is the diagnosis: * 25 year old woman * Presents with 1 year history of lumbar and buttock pain, with morning stiffness lasting 2 hours * Ibuprofen helps * Examination: reduced range of L spine movements

Answer 37

* Inflammatory Spondyloarthritis (SpA) * **Ankylosing spondylitis (AS)** * Psoriatic arthritis * Inflammatory bowel disease (IBD) | Inflammatory (SpA): Group of immune-mediated inflammatory diseases

Question 38

What are the extra-articular manifestations of ankylosing spondylitis (AS)? | 4A

Answer 38

* **Anterior uveitis** (iritis) – ocular inflammation * **Apical lung fibrosis** * **Aortitis** / aortic regurgitation * **Amyloidosis** – due to chronically serum amyloid A (SAA) depositing in organs

Question 39

What is the strongest genetic risk factor for ankylosing spondylitis?

Answer 39

HLA-B27 | +ve in 90% of AS patients versus

Question 40

Which cytokines play important roles in the pathogenesis of ankylosing spondylitis (AS)?

Answer 40

* Tumour necrosis factor alpha (**TNF-alpha**) * interleukin-17 (**IL-17**) * interleukin-23 (**IL-23**)

Question 41

How is ankylosing spondylitis managed?

Answer 41

* **Physiotherapy** and a life-long regular exercise programme * **Pharmacological**

Question 42

What is the 1st line of pharmacological treatment for ankylosing spondylitis (AS)?

Answer 42

* 1st line: non-steroidal anti-inflammatory drugs (**NSAIDs**) * e.g. ibuprofen, naproxen, diclofenac * Mechanism: NSAIDs inhibit cyclooxygenase 1 and 2 (COX1 and 2) * Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk * Selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk

Question 43

What is the 2nd line of pharmacological treatment for ankylosing spondylitis (AS)?

Answer 43

* 2nd line: ‘Biological’ therapies * **Therapeutic monoclonal antibodies (mAbs)** targeting specific molecules * Use if inadequate disease control after trying 2 NSAIDs * **Anti-TNF-alpha** (e.g. adalimumab, certolizumab, infliximab, golimumab) * **Anti-IL17** (e.g. secukinumab)