Back Pain and Spinal Disorders

Question 1

What are the possible psychological effects of back pain?

Answer 1

Emotional stress
Relationship breakdown
Severe emotional distress for partners
Limitations in fulfilling family tasks

Question 2

At what stage is back pain classified as chronic?

Answer 2

> 3 months

Question 3

What structures may be the source of back pain?

Answer 3

Ligaments
Facet joints
Paravertebral muscles and fascia
Discs 
Spinal nerve roots

Question 4

What is the broad differential for back pain?

Answer 4

Mechanical
Systemic (infection, malignancy, inflammatory)
Referred

Question 5

Compare and contrast mechanical and inflammatory back pain?

Answer 5

Mechanical can occur at any age, has a variable onset, <30 mins morning stiffness, exercise often worsens pain, rest often improves pain and pain may improve at night
Inflammatory usually occurs <40 years, has an insidious onset, >30mins morning stiffness, exercise improves pain with no improvement on rest and may have night pain

Question 6

What are the possible causes of non-specific low back pain?

Answer 6

Lumbar strain/sprain
Degenerative disc disease
Degenerative facet joint disease
Disc prolapse
Spinal stenosis
Compression fractures

Question 7

How should non-specific low back pain be managed?

Answer 7

Exercise programmes
Physiotherapy
Patient education
Analgesia - but avoid opiates

Question 8

Which part of the intervertebral disc herniates in a disc prolapse?

Answer 8

Nucleous pulposus

Question 9

Leg pain is worse than back pain in disc prolapse. T/F?

Answer 9

True

Question 10

Most disc prolapses will resolve spontaneously within how many weeks?

Answer 10

12 weeks

Question 11

Surgery for disc prolapse helps only the back pain and not the leg pain. T/F?

Answer 11

False - it only helps the leg pain

Question 12

What is the most common cause of caudal equina syndrome?

Answer 12

large disc prolapse

Question 13

What are the signs/symptoms of caudal equina syndrome?

Answer 13

Neuropathic symptoms of bilateral sciatica and saddle anaesthesia
Bladder or bowel dysfunction with reduced anal tone

Question 14

What is spinal stenosis?

Answer 14

An anatomical narrowing of the spinal canal which can be congenital or degeneration

Question 15

Describe the typical presentation of spinal stenosis

Answer 15

Claudication in the legs and calves which is worse with walking and resting in the flexed position

Question 16

How is spinal stenosis investigated?

Answer 16

X-Ray

MRI

Question 17

What is spondylolithiasis?

Answer 17

A ‘slip’ of one vertebra on to the one below

Question 18

Spondylithiasis is often asymptomatic. T/F?

Answer 18

True

Question 19

Where does pain commonly radiate to in spondylolithesis?

Answer 19

Posterior thigh

Increases with extension

Question 20

What groups of patients commonly get compression fractures?

Answer 20

Elderly patients

Question 21

Where does the pain radiate to in compression fractures?

Answer 21

Radiates in a ‘belt’ around the chest and abdomen

Question 22

What condition is associated with compression fractures?

Answer 22

Osteoporosis

Question 23

How are compression fractures treated?

Answer 23

Analgesia
Calcitonin
Vertebroplasty (cement)
Kyphoplasty (balloon)

Question 24

How are compression fractures investigated?

Answer 24

X-Ray

DEXA scan

Question 25

How soon after a lumbar sprain/strain do muscle spasms usually settle?

Answer 25

24-48 hours

Question 26

What positions or movements increase pain in degenerative disc disease?

Answer 26

Flexion Sitting Sneezing

Question 27

What positions or movements increase pain in degenerative facet joint disease?

Answer 27

Extension

Question 28

What pathologies can cause referred pain in the back?

Answer 28

``` Aortic aneurysm Acute pancreatitis Peptic ulcer disease Acute pyelonephritis / renal colic Endometriosis ```

Question 29

What are the signs and symptoms of an aortic aneurysm?

Answer 29

CVS features such as increased bp and heart rate | Pulsating abdomen mass

Question 30

What are the signs and symptoms of an acute pancreatitis?

Answer 30

Epigastric pain Relief when leaning forwards Unwell

Question 31

What are the signs and symptoms of peptic ulcer disease?

Answer 31

Epigastric pain History of PUD Vomit Blood/malaena

Question 32

What are the signs and symptoms of acute polynephritis or renal colic?

Answer 32

``` History of UTI Unwell Radiation Haematuria Frequency ```

Question 33

What are the signs and symptoms of infective discitis?

Answer 33

Fever Weight loss Constant back pain even at rest and at night

Question 34

What is the most common causative organism of infective discitis?

Answer 34

S.aureus

Question 35

How should possible infective discitis be investigated?

Answer 35

Bloods - FBC, ESR, CRP, blood cultures X-Ray MRI Radiology guided aspiration

Question 36

How is infective discitis treated?

Answer 36

IV antibiotics | Surgical debridement

Question 37

What patients are most at risk of infective discitis?

Answer 37

Immuosuppressed Diabetic patients IVDUs

Question 38

Malignancies of which organs can cause back pain?

Answer 38

``` Lung Prostate Thyroid Kidney Breast ```

Question 39

Malignancy often causes constant back pain which is often worse at night. T/F?

Answer 39

True

Question 40

In what age group does inflammatory back pain usually occur?

Answer 40

Patients <45 years

Question 41

Describe the New York Criteria for ankylosing spondylitis?

Answer 41

Clinical criteria: low back pain and stiffness for more than 3 months which improves with exercise, but is not relieved by rest Limitation of motion of the lumbar spine in both the sagittal and frontal planes Limitation fo chest expansion relative to normal values correlated for age and sex Sacroilitis grade >2 bilaterally or grade 3-4 unilaterally

Question 42

What are the symptoms of axial spondyloarthritis?

Answer 42

Inflammatory back pain Fatigue Arthritis in other joints: hips, knees Enthesitis: achilles tendon, plantar fasciitis Inflammation outside the joints - uveitis, psoriasis, churn's disease, inflammation of heart/lungs

Question 43

Which gene can predispose to ankylosing spondylitis or axial spondyloarthritis?

Answer 43

HLA-B27 gene

Question 44

How is inflammatory back pain treated?

Answer 44

``` NSAIDs Biologic drugs Education Exercise Physical therapy Rehabilitation Self-help groups ```

Question 45

What are the red flag symptoms of back pain?

Answer 45

``` New onset <16 or >50 years Following significant trauma Previous malignancy Systemic - fevers, riggers, general malaise, weight loss Previous steroid use IV drug abuse, HIV or immuocompromised Recent significant infection Urinary retention Non-mechanical pain Thoracic spine pain ```

Question 46

What are the red flag signs of back pain?

Answer 46

``` Saddle anaesthesia Reduced anal tone Hip or knee weakness Generalised neurological deficit Progressive spinal deformity ```

Question 47

What are the yellow flag signs of back pain?

Answer 47

Bio-psycho social model to assess patients likely to develop chronicity: Attitudes, beliefs, compensation, diagnosis, emotions, family, word relationship