LBP, Neck Pain + Osteoporosis

Question 1

Serious causes of LBP to be r/o

Answer 1

Cauda Equina
Pyelonephritis
AAA rupture
Cancer

Question 2

Signs of AAA

Answer 2

pulsatile mass, pain, hypotension

Question 3

Causes of neck pain

Answer 3

Lymphoma
Carotid dissection
Referred pain: MI, pseudotumour cerebri
Nerve/ spinal cord compression
Muscular neck pain
Degenerative disc disease

Question 4

What are the C spine rules for XR?

Answer 4

Any high risk features?
Age ≥65yr or
Dangerous mechanism* or
Paresthesias in extremities

If yes - XR
If no:

Any low risk features?
Simple rear-end MVC** or
Sitting position in ED or
Ambulatory at any time or
Delayed onset of neck pain*** or
Absence of midline cervical spine tenderness

If no - XR
If yes:

Is pt able to actively rotate neck left and right 45 degrees?

Yes: cleared
No: XR

Question 5

What are the dangerous mechanisms for C spine injury?

Answer 5

Fall from elevation ≥91.5cm/5 stairs
* Axial load to head, eg diving
* MVC high speed (>100km/h),
rollover, ejection
* Motorised recreational vehicles
* Bicycle crash

Question 6

Dx of OP

Answer 6

Fragility # hip or spine
Low BMD (<-2.5)
High FRAX score + T score <-1
Fragility # + T score <-1

Question 7

definition of Fragility fracture

Answer 7

after age 40: spontaneous # or # from minor trauma

Question 8

Primary prevention of OP

Answer 8

Calcium
Physical activity - strength, balance + aerobics
Smoking cessation
Hip protectors
Advise on fracture prevention
Physical fitness
Reduce alcohol
Smoking cessation
Risk of physical abuse
Environmental factors contributing to falls
Meds contributing to falls

Question 9

Reasons to screen for osteoporosis

Answer 9

Age over 65
Age over 40 + Fragility Fracture
Prolonged Glucocorticoids (>3months)
Family History of Hip Fractures
Presence of Vertebral Fracture
Evidence of Osteopenia on X-Ray
Smoking
EtOH Intake
Early Menopause (age <45)
Rheumatoid Arthritis
Primary Hyperparathyroidism
Hypogonadism
Low Body Weight (<60kg)
Major Weight Loss (>10% loss at age 25)
Malabsorption Syndrome

Question 10

T scores for osteopenia + osteoporosis

Answer 10

Osteopenia: -1.0 to -2.5 SD
Osteoporosis: -2.5 or less

Question 11

Indication for BMD in
<50

Answer 11

Fragility #
Prolonged steroid use
High risk med (aromatase inhibitors, androgen deprivation therapy)
Hypogonadism
Premature menopause
Malabsorption syndrome
Primary hyperparathyroidism

Question 12

Indication for BMD in >50

Answer 12

Age >65
Fragility # >40 y/o
Prolonged steroids
Parental hip #
Smoker
High alcohol intake
Wt <60kg
RA
High risk med (aromatase inhibitors, androgen deprivation therapy)

Question 13

Ix after Dx of OP

Answer 13

Calcium corrected with albumin
CBC
Cr
ALP
TSH
SPEP if vertebral #

Question 14

Secondary causes of OP

Answer 14

Endo: acromegaly, DM, hyperparathyroidism, hyperthyroidism, hypogonadism, low phosphate, porphyria, pregnancy
GI: alcoholism, anorexia, liver dz, malabsorption
Drugs: anti-epileptics, aromatase inhibitors, immunosuppressants, lithium, PPI, SSRI
Other: COPD, HIV, AS, hemophilia, MDD, myeloma, CKD, RA

Question 15

Management - 10 yr # risk <10%

Answer 15

<10%:
Lifestyle
Calcium/Vitamin D
Repeat BMD in 5 years

Question 16

Management - 10 yr # risk 10-20%

Answer 16

Lifestyle
Calcium/Vitamin D
Lateral thoracolumbar XR (T4-L4)

If RF present, start meds. No RF, repeat BMD in 1-3yrs.

RF:
additional vertebral #s
prev wrist #
lumbar spine T score &laquo_space;femoral neck T score
Rapid bone loss
Androgen deprivation therapy for prostate cancer
Longterm steroids
Recurrent falls

Question 17

Management - 10 yr # risk >20%:

Answer 17

Lifestyle
Calcium/Vitamin D

Women: bisphosphonate, denosumab if v high risk
Men: alendronate, zoledronic acid

Bisphosphonates
Alendronate 70mg weekly or risedronate 35mg weekly

Question 18

SE, how to mitigate + “drug holiday” of bisphosphonates

Answer 18

Drug holiday after 10 yrs
SE: Esophagitis, Dyspepsia, Nausea
Bisphosphonates advice: take sitting up, half hour before meals, empty stomach, plenty of water

Question 19

What rule to use in <16 y/o for ?C spine fracture + what are the components

Answer 19

NEXUS
C spine not necessary if they have an Alert MIND:
Alert
No midline tenderness
No intoxication
No neuro deficit
No distracting injury

Question 20

Types of unstable cervical fractures

Answer 20

Jefferson’s fracture (C1 compression), Hangman’s fracture (C2 bilat pars), bilateral cervical facet dislocation, odontoid, atlanto-occipital dissociation

Question 21

Red flags in neck pain

Answer 21

ripping/ tearing sensation, concurrent CP, wt loss, immunosuppression, IVDU, neuro deficit, vision changes, hx of malignancy

Question 22

What is the safety issue with neck pain?

Answer 22

Driving

Question 23

Neck pain in RA = what?

Answer 23

atlanto axial disruption

Question 24

Who is not eligible for bisphosphonate drug holiday

Answer 24

vertebral + hip fractures

Question 25

FRAX score components

Answer 25

WASH F SCRAPS
wt
age
sex
ht

femoral neck bmd

steroids
current smoking
RA
alcohol >3/d
parent hip frac/ prev frac
secondary OP

Question 26

When to start bisphosphonate?

Answer 26

If FRAX score >20% or confirmed OP

Question 27

OP dx clinically (not using BMD)

Answer 27

take height yearly, if loss of height by 2cm prospective or 6cm historical, look for vertebral fractures - fractures = OP

Question 28

When to order BMD

Answer 28

if at risk or had fracture

Question 29

What labs to order w/ vertebral fractures?

Answer 29

Hb, TSH, ionized Ca, Alk Phos, Cr, SPEP, vit D

Question 30

How much Ca + Vit D to advise people to have?

Answer 30

1000mg calcium, 1000U Vit D

Question 31

SE bisphosphonates

Answer 31

esophageal ulcer, increased atypical fractures, jaw osteonecrosis

Question 32

Class + SE of raloxifene

Answer 32

selective estrogen receptor modulator. VTE + PE

Question 33

What to use for high risk OP pts?

Answer 33

Denosumab (monoclonal ab)

Question 34

SE denosumab

Answer 34

joint pain, jaw osteonecrosis

Question 35

Drug holidays in OP

Answer 35

drug holiday for 5 yrs after been on drug for 5 yrs, except high risk pts

Question 36

RED-S - what is it?

Answer 36

relative energy deficiency in sport
low caloric intake, +/- disordered eating, amenorrhea, low BMD

Question 37

Rx for OP

Answer 37

bisphosphonates, raloxifene (selective estrogen receptor modulator) + teriparatide (PTH analog), denosumab (MAB)