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Week 11- Musculoskeletal > Back pain and spinal disorders > Flashcards

Back pain and spinal disorders Flashcards

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1
Q

What is the definition of chronic back pain?

A

Back pain lasting at least 3 months

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2
Q

What are the broad causes of back pain?

A
  • Mechanical (97%)
  • Referred
  • Systemic
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3
Q

Describe non specific lower back pain

A
  • Onset at any age with a variable rate
  • Generally worsens with movement or prolonged standing
  • Gets better with rest
  • Early morning stiffness <30 minutes
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4
Q

What are the causes of non specific lower back pain?

A
  • Lumbar strain/sprain
  • Degenerative discs/facet joints
  • Disc prolapse, spinal stenosis
  • Compression fractures
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5
Q

What is the most common cause of mechanical back pain?

A

Lumbar strain/sprain

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6
Q

Describe pain in degenerative disc disease (Spondylitis)

A
  • For many it is an asymptomatic disc disease

* Pain increases with flexion, sitting, sneezing

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7
Q

Describe pain in degenerative facet joint disease

A
  • more localised

* Increased with extension

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8
Q

What is the management of non specific lower back pain?

A
  • Keep the diagnosis under review
  • Reassure patient (majority settles within 3 months of symptom onset)
  • Education, promote self management
  • Exercise programme and physiotherapy
  • Analgesics as appropriate but avoid opiates
  • Acupuncture
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9
Q

What should be avoided in the management of non specific lower back pain?

A
  • Injections
  • Traction
  • Lumbar supports
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10
Q

What determines the symptoms experienced in patients with a disc herniation?

A

Which nerve it is compressing

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11
Q

Where do discs herniate?

A

Straight back compressing the spinal cord or to the side compressing the nerve root

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12
Q

What is a radiculopathy

A

The symptoms that occur when a nerve is pinched/compressed

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13
Q

Describe the signs of a disc prolapse/herniated nucleus pulposus

A
  • May be acute
  • Typically leg pain over back pain (sciatica)
  • Straight leg raising test will be positive
  • Reduced reflexes
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14
Q

Describe the management of a disc prolapse

A
  • Most resolve spontaneously within 12 weeks
  • Wait with investigations i.e. MRI and only do if it is not settling
  • 10% will need surgery but this tends to help the leg pain and not the back, there is no clear benefit of surgery at 1 year
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15
Q

What cause of back pain warrants an urgent neurosurgical review?

A

Cauda equina syndrome

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16
Q

What level does the spinal cord end?

A

L1/2

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17
Q

What are the symptoms of cauda equine syndrome?

A
  • neuropathic symptoms: bilateral sciatica, saddle anaesthesia
  • Bladder or bowel dysfunction: reduced anal tone
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18
Q

What is the usual cause of cauda equina syndrome?

A

A large prolapsed disc

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19
Q

What is spinal stenosis?

A

Anatomical narrowing of the spinal canal - can be congenital and/or degenerative

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20
Q

What is the presentation of spinal stenosis?

A
  • Often presents with claudication in the legs/calves, worse when walking
  • Normally both legs, if just one, think vascular
  • Natural history is variable
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21
Q

What investigations should be carried out in suspected spinal stenosis?

A

X ray and MRI but only if the diagnosis is uncertain or imaging will alter management

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22
Q

What is spondylolisthesis?

A

Slip of one of the vertebra on the one below

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23
Q

Describe pain in spondylisthesis?

A
  • May radiate to the posterior thigh

* Increases with extension

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24
Q

Where may there be a defect in someone with spondylolisthesis?

A

Pars interarticularis

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25
Describe pain in a compression fracture
*  Often sudden onset and severe *  Radiates in a belt around the chest/abdomen *  Most pain settles in 3 months
26
What is a compression fracture associated with?
*  Old age | *  Osteoporosis
27
What investigations can be carried out for a compression fracture?
*  X ray | *  DEXA (bone density scan)
28
What is the treatment for a compression fracture?
*  Conservative (analgesia) *  Calcitonin *  Vertebroplasty (cement) or kyphoplasty (balloon)
29
What can present as referred back pain?
*  Aortic aneurysm *  Acute pancreatitis *  Peptic ulcer disease (duodenal) *  Acute pyelonephritis *  Endometriosis/gynae
30
What are the symptoms of aortic aneurysm?
*  CVS features (BP and tachycardia) *  pulsating abdo mass *  Collapse
31
What are the symptoms of acute pancreatitis?
*  Epigastric pain *  Relief on leaning forwards *  Systemically unwell
32
What are the symptoms of peptic ulcer disease?
*  Epigastric pain, especially after meals *  history of peptic ulcer disease *  Vomiting blood *  malaena
33
What are the symptoms of acute pyelonephritis
*  History of UTI/stones *  Unwell *  Haematuria *  Frequency
34
What are the systemic causes of back pain?
*  Infection: discitis, osteomyelitis, epidural abscess *  Malignancy *  Inflammatory
35
What are the symptoms of infective discitis?
*  Fever (May be a pyrexia of unknown origin) *  Weight loss *  Constant back pain, on rest and at night
36
What is a typical PMH of someone presenting with infective discitis?
*  Immunosuppressed *  Diabetes *  IV drug user
37
What investigations should you carry out in suspected infective discitis?
*  FBC, ESR, CRP *  blood cultures *  Imaging: X ray/ MRI (x ray can be normal at beginning) *  Radiology guided aspiration
38
What is the most common cause of infective discitis?
Staph aureus
39
What is the treatment of infective discitis?
IV antibiotics +/- surgical debridement
40
What is the appearance of infective discitis on Xray?
*  can't see the disc space (can heal with complete loss of the disc space) *  Changes on both sides of the vertebrae
41
Which cancers are most likely to metastasise to the spine?
*  Lung *  Prostate *  Thyroid *  Kidney *  Breast
42
What are the symptoms of malignancy in the spine?
*  Constant pain, often worse at night | *  Systemic symptoms, primary tumour signs and symptoms
43
Describe malignancy in the spine on xray
Margin tends to be normal on one side and abnormal on the other
44
Describe the symptoms of inflammatory back pain
*  Early morning stiffness lasting >30 mins *  Back tends to be stiff after rest and improves with movement *  may wake in the 2nd half of the night with buttock pain
45
What is the rule of 10s?
*  Of all patents with chronic lower back pain, 10% will have inflammatory symptoms *  1% will have Ankylosing spondylitis or axial spondyloarthritis
46
What are the red flag signs when someone is presenting with back pain?
*  New onset age <16 or >50 *  Following significant trauma *  Previous malignancy *  Systemic: fevers/rigors, general malaise, weight loss *  Previous steroid use *  IV drug abuse, HIV or immunocompromised *  Recent significant infection *  Urinary retention *  Non mechanical pain or pain worse at night *  Thoracic spine pain *  Signs: saddle anaesthesia, reduced anal tone, hip or knee weakness, generalised neurological defect, progressive spinal deformity
47
What are the types of inflammatory back pain?
*  Ankylosing spondylitis *  non-radiographic axSpA *  Other
48
What are the predictors of progression of axSpA
*  Smoking * Existing damage * Male
49
What is the common presentation of an inflammatory back pain?
*  Onset less than 45 years old * Early morning stiffness >30mins *  Back stiff after rest and improves with movement *  may wake in the second half of the night *  Buttock pain
50
What are the spondyloarthritis features?
*  Inflammatory back pain *  Arthritis *  Enthesitis (heel) *  Uveitis *  Dactylitis *  Psoriasis *  Chrons/colitis *  Good response to NSAIDs *  Family history for SpA *  HLA-B27 *  Elevated CRP
51
What is the ASAS classification criteria for axial SpA?
In patients with a >/3 month history of back pain and age at onset less than 45 years: • Sacroilitiis on imaging with at least one SpA feature OR • HLA-B27 with at least 2 SpA features
52
What is the difference between classification and diagnostic criteria?
*  In classification criteria the diagnosis is already known and you do not have to exclude other potential causes *  Diagnostic criteria the diagnosis is not yet known and you require the exclusion of other potential causes for symptoms/results
53
What are the symptoms of axial spondyloarthritis?
``` • Inflammatory back pain • Fatigue • Arthritis in other joints: knees, hips • Enthesitis: Achilles tendon, plantar fasciitis • Inflammation outside joints: - eye= uveitis - skin: psoriasis - Bowel: churns disease/UC - Other: heart, lungs, osteoporosis • Family history of above ```
54
What is the recommended imaging for axSpA?
* Pelvic AP Xray *  Lumbar spine X ray *  MRI allows for the earlier identification of macro-ilitis
55
Describe the appearance of the lumbar spine on X ray in ankylosing spondylitis
*  Sclerosis - shiny corners of vertebrae *  Syndesmophytes and spondylophytes (look like notches on the anterior aspect of the spine) *  Bridging syndesmophytes
56
What are the mimics of ankylosing spondylitis on MRI?
*  Infective sacro-iliits | *  Insufficiency fracture
57
Give an overview of the process of diagnosing ankylosing spondylitis and
*  Someone comes in with features suggestive of a diagnosis *  Imaging supports this *  Look for associated features: family history and extra articular features *  Other investigations: HLA-B27 status and CRP/ESR
58
Why do people get axSpA and AS?
*  Genetic susceptibility: HLA-B27 positive, IL-23R, Th17 response *  Environment: infection and microbiome in the gut/on the skin *  Biomechanics
59
Explain the IL-23 and IL-17 pathway in enthesitis and axSpA
*  Gut microbiome, HLA-B27 and biomechnaical stress cause an increase in the production of IL-23 *  IL-23 causes T cell to release cytokines and causes the increase of IL-22 and IL-17 *  IL-22 causes osteoproliferation and IL-17 causes bone loss, both IL-22 and IL-17 cause inflammation * This combined effect results in ankylosis
60
what can patients with ankylosing spondylitis and axial spondyloarthritis do to help themselves?
*  Exercises *  Stop smoking *  Self management strategies *  healthy diet and sleep
61
What are the treatment options for axSpA?
*  NSAIDS *  Analgesics *  Surgery *  Biologic drugs: TNF inhibitors and IL-17A inhibitors

Week 11- Musculoskeletal (11 decks)

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