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BRS MUSCULOSKELETAL And RHEUM > Back Pain > Flashcards

Back Pain Flashcards

(60 cards)

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1
Q

What are the functions of the spine (3)?

A
  • Locomotor: capable of being both rigid & mobile
  • Bony armour: protects the spinal cord
  • Neurological: spinal cord transmission of signals between brain & periphery
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2
Q

How many vertebrae does the spinal column consist of?

24 bones

A
  • 7 cervical
  • 12 thoracic
  • 5 lumbar

24 total

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3
Q

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

A
  • Shock absorbers
  • Allow segmentation & multi-directional movement
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4
Q

What are the facet joints of the spinal column?

A
  • Small synovial joints at posterior spinal column linking each vertebra
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5
Q

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

A
  • Move the spine
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6
Q

What is Lordosis

A

Normal curvature of the lower spine

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7
Q

What is kyphosis

A

The outward curve of the thoracic spine

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8
Q

Where does the spinal cord end?

A

L2

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9
Q

What is found after the spinal cord?

A

Cauda equina

Cauda equina: nerve bundle

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10
Q

At what level is a lumbar puncture performed?

A

L3/4 to avoid spinal chord damage

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11
Q

What are the two components of the intervertebral disc?

A

Nucleus pulposus
Annulus fibrosus

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12
Q

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

A
  • Flexion (forward bend) vs extension (backward bend)
  • Lateral flexion (side bend)
  • Rotation (twist)
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13
Q

Outline the epidemiology of back pain?

Common
Effect
When does it get better

A
  • 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
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14
Q

What are the causes of back pain differentiated into?

A
  • Mechanical back
  • Non-specific
  • Nerve root back pain
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15
Q

What are the signs and symptoms of mechanical back pain?

When it comes to movement and rest

A
  • Reproduced or worse with movement
  • Better or not present at rest
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16
Q

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

A
  • Muscular tension (e.g. chronic poor posture, weak muscles)
  • Acute muscle sprain / spasm
  • Degenerative disc disease
  • Osteoarthritis of facet joints
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17
Q

What symptom may is common with mechanical back pain?

Mechanical back pain caused by disc herniation

A
  • Sciatica

Sciatica: pain radiating down one leg

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18
Q

What causes sciatica?

A

Disc herneation (slipped disc) which then comes into contact with the exiting lumbar nerve root

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19
Q

What determines the location of pain caused by sciatica?

A
  • Level of the herniated disc
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20
Q

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

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

Referred pain (pancreas, kidneys, aortic aneurysm)

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21
Q

what infective condition can commonly cause back pain?

A

TB- insidious onset

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22
Q

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

A
  • Metastatic cancer
  • Myeloma
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23
Q

What serious infections can cause back pain (6)?

A
  • Discitis
  • Vertebral osteomyelitis
  • Paraspinal abcess
  • Microbiology:
    • Staphylococcus
    • Streptococcus
    • Tuberculosis (TB)
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24
Q

What inflammatory spondyloarthropathy can cause back pain (3)?

A
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Inflammatory bowel disease (IBD) - associated
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25
What are the "red flag" symptoms of back pain that may indicate serious pathology (10)?
* **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
26
What are the symptoms / signs of cauda equina syndrome (5)? ## Footnote * Cauda equina syndrome is a neurosurgical emergency * Untreated = permanent lower limb paralysis and incontinence
* **Saddle anaesthesia** * Bladder / bowel **incontinence** * **Loss of anal tone on PR** * **Radicular leg pain** * **Ankle jerks** may be absent
27
What investigation is required in suspected cauda equina syndrom? ## Footnote * Cauda equina syndrome is a neurosurgical emergency * Untreated = permanent lower limb paralysis and incontinence
* **Urgent MRI of lower spine**
28
What are the causes of cauda equina syndrome (5)?
When the nerves which run lower than L1 are compressed: * Large disc herniation * Bony mets * Myeloma * TB * Paraspinal abcess
29
If untreated what does CES lead to?
* CES is a neurosurgical emergency * If untreated can cause permanent lower limb paralysis and incontinence
30
What is the treatment of cauda equina syndrome?
* According to cause: may require **urgent surgery**
31
In which situation is imvestigations not usually required?
in the absence of red flags
32
What is the treatment for low back pain without red flags (4)?
* **Time** * **Analgesia** (NSAIDs e.g. ibuprofen, paracetamol, codeine) * **AVOID bed rest**: keep moving * **Physiotherapy** * Soft tissue work * Corrective exercises esp. core
33
What investigations (blood test) are recommended for back pain (6)?
* Erythrocyte sedimentation rate (ESR) * C-reactive protein (CRP) * Full blood count (FBC) * Alkaline phosphatase (ALP) * Calcium * PSA (prostate specific antigen)
34
When is erythrocyte sedimentation rate (ESR) abnormal in back pain?
Increased in: * Myeloma * Chronic inflammation * TB
35
When is C-reactive protein (CRP) abnormal in back pain?
Increased in: * Infection * Inflammation
36
When is alkaline phosphatase (ALP) abnormal in back pain?
Increase in: * Bony metastases (mets)
37
When is calcium abnormal in back pain?
May be increased in: * Myeloma * Bony metastases (mets)
38
When is full blood count (FBC) abnormal in back pain?
* Anaemia in: * Myeloma * Chronic disease * Increase in: * WCC in infection
39
When is PSA (prostate specific antigen) abnormal in back pain?
Increased in: * Prostate cancer with bony mets
40
What investigations (imaging) are recommended for back pain (3)?
* **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
41
What is the diagnosis and does she need investigation?: * 70 year old woman * Acute onset thoracic spine pain with radiation through to the chest wall * Focally tender over thoracic spine
* Thoracic = red flag so needs investigation * **Osteoporotic vertebral collapse** * “Wedge fracture”
42
What is a wedge fracture?
A compression fracture of the spinal column in which the front side of the spine collapses, resulting in a wedge shape
43
What is the diagnosis and does he need investigation?: * 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
Needs investigation (weight loss, night sweats) * **L4/5 endplate destruction** * Soft tissue mass encroaching spinal canal * T2: altered signal in sacral segments
44
How is a herniated disc managed (3)?
* **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
45
What is the conservative treatment of a herneated disk?
* **Analgesia** especially NSAIDs * **Physiotherapy** to improve core strength and treat associated muscle spasm
46
What is the nerve root injection for a herneated disk?
local anaesthetic and glucocorticoid
47
When would surgery be considered for a herniated disc?
If neurological compromise or symptoms persist
48
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
Herniated discs
49
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
* Inflammatory Spondyloarthritis (SpA) * **Ankylosing spondylitis (AS)** * Psoriatic arthritis * Inflammatory bowel disease (IBD) | Inflammatory (SpA): Group of immune-mediated inflammatory diseases
50
What is inflammatory spondyloarthritis?
Primary inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-illitis) Peripheral joints, esp. tendon insertions (entheses), can also be affected
51
What are the extra-articular manifestations of ankylosing spondylitis (AS)? | 4A
* **Anterior uveitis** (iritis) – ocular inflammation * **Apical lung fibrosis** * **Aortitis** / aortic regurgitation * **Amyloidosis** – due to chronically serum amyloid A (SAA) depositing in organs
52
What effect does ankylosing spondilitis have on the spine?
Loss of spinal moevements
53
What is the pathophysiology of ankylosing spondylitis?
Charactarised by enthesitis (inflammation of the entheses- sites where tendons and ligaments join to bone)
54
What is the strongest genetic risk factor for ankylosing spondylitis?
HLA-B27 | +ve in 90% of AS patients versus
55
Which 3 cytokines play important roles in the pathogenesis of ankylosing spondylitis (AS)?
* Tumour necrosis factor alpha (**TNF-alpha**) * interleukin-17 (**IL-17**) * interleukin-23 (**IL-23**)
56
What is the natural progression of AS?
Spinal enthesitis -> Bridging syndesmophytes (new bone growth between adjacent vertebra) -> Spinal fusion
57
What is seen on an MRI of the spine in a patient with AS?
Shiny corners sign
58
How is ankylosing spondylitis managed?
* **Physiotherapy** and a life-long regular exercise programme * **Pharmacological**
59
What is the 1st line of pharmacological treatment for ankylosing spondylitis (AS)?
* 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
60
What is the 2nd line of pharmacological treatment for ankylosing spondylitis (AS)?
* 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)

BRS MUSCULOSKELETAL And RHEUM (17 decks)

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