Back pain

Question 1

Functions of the spine

Answer 1

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

Question 2

Key MSK structures of the spine

Answer 2

1. Spinal column consisting of
   A) 24 vetebrae (7 cervical, 12 thoracic, 5 lumbar)
   B) intervertebral discs (act as shock absorbers, allow segmentation and multi-directional movement)
   C) facet joints (small synovial joints at posterior spinal column linking each vertebra)
2. Muscles- move the spine

Question 3

Where do you see normal kyphosis and normal lordosis in the spine

Answer 3

Cervical spine, lumbar spine- normal lordosis
Thoracic spine- normal kyphosis

Question 4

Key neurological structures structures of spine

Answer 4

Spinal cord- transmission of signals from brain, ends at L2 spinal level
Nerve roots- exit spinal cord bilaterally
Cauda equina- nerve bundle

Question 5

Movements of the spine

Answer 5

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

Question 6

How common is back pain

Answer 6

Very common, >50% of people will experience an episode

Question 7

Is acute back pain self limiting.

Answer 7

Usually yes, most better in a few days, 96% better in 6 weeks

Question 8

What time duration of back pain qualifies for chronic back pain. How common is it and name a common risk factor

Answer 8

12 weeks
Also very common
Caused by sedentary lifestyle

Question 9

Mechanical back pain exacerbating/ relieving factors?

Answer 9

Reproduced or worse with movement
Better or not present at rest

Question 10

Common causes of mechanical back pain

Answer 10

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

Question 11

What is sciatica?
What is the typical cause of sciatica?
What determines the location of pain of sciatica?

Answer 11

Pain radiating down one leg (may accompany mechanical back pain
Typically caused by disc herniation (nucleus pulposus herniates through annulus fibrosus) contacting the exiting lumbar nerve root
Location of pain is determined by level of herniated disc

Question 12

Serious causes of back pain

Answer 12

Tumor- metastatic, myeloma
Infection- discitis, vertebral osteomyelitis, paraspinal abscess (microbiology- staphylococcus, streptococcus, TB)
Inflammatory spondyloarthropathy- ankylosing spondylitis, psoriatic arthritis, IBS-associated
Fracture- traumatic/ atraumatic (osteoarthritis)
Large disc prolapse causing neurological compromise
Referred pain- pancreas, kidneys, aortic aneurysm

Question 13

Red flag symptoms of back pain

Answer 13

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 14

What syndrome associated with back pain is a neurological emergency and why?

Answer 14

Cauda equina syndrome
Untreated, will lead to permanent lower limb paralysis and incontinence

Question 15

Symptoms/ signs of Cauda equina syndrome

Answer 15

Saddle parasthesia
Loss of anal tone or PR
Radicular leg pain
Ankle jerks may be absent
Bladder/ bowel incontinence

Question 16

Cauda equina syndrome investigation

Answer 16

Urgent MRI lumbar spine

Question 17

Causes of Cauda equina syndrome

Answer 17

Large disc herniation
Bony mets/ myeloma
TB
Paraspinal abscess

Question 18

Treatment of Cauda equina syndrome

Answer 18

According to cause, may require urgent surgery

Question 19

Back pain: history-taking- what is included?

Answer 19

Site & pattern
Character (e.g. aching, throbbing, burning, electricity)
Onset
Prolonged morning stiffness
Exacerbating/relieving factors
Effect of movement vs. inactivity
Radiation (e.g. sciatica)
Buttock pain
Leg weakness
Sensory loss/paraesthesia
Lower limb claudication ((peripheral vascular disease, spinal stenosis))

Question 20

What is involved in examination of the spine?

Answer 20

Look
Feel
Move
Straight leg raise (SLR) ((lie flat, lift leg straight up, if sciatica, at some point symptoms reproduced))
Lower limb neurological exam
General exam (signs of malignancy, AAA)

Question 21

What investigations are carried out for back pain?

Answer 21

In the absence of red flags, investigation usually not required
Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care
Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause

Question 22

Treatment for low back pain without red flags

Answer 22

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

Question 23

What types of investigations are used for back pain?

Answer 23

Blood tests, radiographs (Xray), CT, MRI

Question 24

What can different blood results indicate with regards to back pain?

Answer 24

Question 25

Pros and cons of radiography, CT, MRI

Answer 25

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 26

What does this image show? Possible cause?

Answer 26

"Wedge fracture"/ vertebral collapse Can be caused by osteoporotic weakening

Question 27

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 Differential?

Answer 27

TB! (cancer less likely because young) Nepal is an indicator

Question 28

In what age groups are herniated discs most common

Answer 28

30-50

Question 29

Natural history for herniated disc

Answer 29

Good outlook Normally spontaneous improvement, although typically slower than for low back pain alone

Question 30

Treatment of herniated disc

Answer 30

1. Conservative as for LBP without sciatica -Analgesia especially NSAIDs -Physiotherapy to improve core strength and treat associated muscle spasm 2. Nerve root injection (local anaesthetic and glucocorticoid) 3. Surgery if neurological compromise or symptoms persist (Trials of surgery vs conservative Rx show no long term advance for surgery)

Question 31

Can slipped discs resolve spontaneously

Answer 31

Yes, sequential MRI studies show that herniated portion of the disc tends to regress with time with partial or complete resolution in two thirds of cases after six months.

Question 32

What is inflammatory spondyloarthropathy? Give examples

Answer 32

Group of immune-mediated inflammatory diseases Ankylosing spondylitis (AS)((loss of spinal movements, severe spinal deformity)), psoriatic arthritis and inflammatory bowel disease (IBD)

Question 33

What joins are affected in inflammatory spondyloarthropathy?

Answer 33

Primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis) Peripheral joints, esp. tendon insertions (entheses), can also be affected- this can cause dactylitis/ sauasage fingers

Question 34

Extra-articular manifestations of inflammatory spondyloarthropathy?

Answer 34

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

Question 35

Pathophysiology of ankylosing spondylitis

Answer 35

Characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone) Large genetic component Many genetic variants associated with the disease (polygenic) HLA-B27 is the strongest genetic risk factor HLA = a region on chromosome 6 encoding MHC molecules HLA-B27 is a class 1 MHC molecule Cells present peptides to CD8 T cells in association with MHC class 1 molecules HLA-B27 +ve in 90% of AS patients versus ~10% in general population Used as a diagnostic biomarker but HLA-B27 +ve alone does not equal AS Cytokines play important roles in pathogenesis tumour necrosis factor alpha (TNF-alpha) interleukin-17 (IL-17) interleukin-23 (IL23) Aberrant peptide processing pathways (aminopeptidases) in the endoplasmic reticulum

Question 36

What can you see in imaging of sacroiliac joint in ankylosing spondylitis

Answer 36

Irregular SI joint, increased whitening on either side

Question 37

Imaging in ankylosing spondylitis: Sacro-iliitis on MRI

Answer 37

Question 38

Natural history of untreated Ankylosing Spondylitis

Answer 38

Spinal enthesitis -> Bridging syndesmophytes (new bone growth between adjacent vertebra) -> Spinal fusion

Question 39

Spinal MRI in Ankylosing Spondylitis-Advantage over Xray? What is an MRI sign of AS on MRI?

Answer 39

MRI can detect spinal inflammation before X-rays changes develop In image we see “Shiny corners” sign at L4, L5 and S1

Question 40

Management of ankylosing spondylitis

Answer 40

1) Physiotherapy and a life-long regular exercise programme 2) Pharmacological 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 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)