🩻MSK🩻 - Back Pain

Question 1

What are the 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

What is the spinal column made up of?

Answer 2

24 Vertebrae
-7 cervical
-12 thoracic
-5 lumbar
Intervertebral discs
Facet joints – small synovial joints at posterior spinal column linking each vertebra
Muscles – move the spine

Question 3

What are the key neurological structures of the spine?

Answer 3

Spinal cord - transmission of signals to/from brain. Ends at L2 vertebra
Nerve roots - exit spinal cord bilaterally
Cauda equina - nerve bundle

Question 4

Where is a lumbar puncture performed and why?

Answer 4

L3/L4 space to avoid spinal cord which ends at L2

Question 5

Describe the movements of the spine

Answer 5

Question 6

Outline back pain

Answer 6

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 pain from serious pathology

Question 7

What is mechanical back pain?

Answer 7

Reproduced or worse with movement
Better or not present at rest

Question 8

What are the most common causes of mechanical back pain?

Answer 8

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

Question 9

What is sciatica?

Answer 9

Pain radiating down a leg

Question 10

How does sciatica tend to arise?

Answer 10

Disc herniation (“slipped disc”) contacting the exiting lumbar nerve root

Question 11

What are the serious pathological causes of back pain?

Answer 11

Tumour - metastatic cancer or myeloma
Infection - Discitis, Vertebral osteomyelitis, Paraspinal abcess, Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)
Inflammatory spondyloarthropathy
Fracture (traumatic or atraumatic)
Large disc prolapse causing neurological compromise
Referred pain

Question 12

What are inflammatory spondyloarthropathies?

Answer 12

Group of immune-mediated inflammatory diseases
Ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD)

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

Question 13

What are the extra-articular manifestations of Inflammatory Spondyloarthritis (SpA)?

Answer 13

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

Question 14

What is meant by “referred pain” in the context of serious back pain pathologies?

Answer 14

Pain referred from more serious conditions, such as pancreatic disease/cancer, kindey disease/injury/cancer and aortic aneurysms

Question 15

What are the “red flag” symptoms in back pain?

Answer 15

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 16

What is cauda equina syndrome?

Answer 16

Nerves at the base of the spinal cord (cauda equina) are compressed
Neurosurgical emergency
Untreated = permanent lower limb paralysis and incontinence

Question 17

What are the symptoms and signs of cauda equina syndrome?

Answer 17

Saddle anaesthesia
Bladder/bowel incontinence
Loss of anal tone
Radicular (bilateral shooting) leg pain
Ankle jerks may be present

Question 18

What is the investigation for suspected cauda equina syndrome?

Answer 18

Urgent MRI L spine

Question 19

What are some of the causes of cauda euina syndrome?

Answer 19

Large disc herniation
Bony mets
Myeloma
TB
Paraspinal abscess

Question 20

What is the treatment for cauda equina syndrome?

Answer 20

According to cause - often urgent surgery

Question 21

What should be asked when taking a history of back pain?

Answer 21

Site/pattern
Onset
Character (aching, throbbing, burning, electric)
Radiation (e.g. sciatica)
Associated symptoms (morning stiffness, buttock pain, leg weakness, paraesthesia/numbness)
Time
Exacerbating/relieving factors (effect of movement vs inactivity)
Severity

Question 22

How is the spine examined?

Answer 22

Look
Feel
Move
Straight leg raise (SLR)
Lower limb neurological exam
General exam (signs of malignancy, AAA)

Question 23

What is the guidance for investigation of back pain?

Answer 23

In the absence of red flags, investigation usually not required
Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause

Question 24

What is the treatment for lower back pain without any red flags?

Answer 24

Question 25

What are the blood investigations for back pain?

Answer 25

ESR CRP FBC Alkaline phosphatase (ALP) Calcium PSA

Question 26

What would an abnormal ESR indicate?

Answer 26

Myeloma, chronic inflammation, TB

Question 27

What would an abnormal CRP indicate?

Answer 27

Infection or inflammation

Question 28

What would an abnormal FBC indicate, in the context of back pain?

Answer 28

Anaemia in myeloma, chronic disease, increased WCC in infection

Question 29

What would an abnormal ALP indicate?

Answer 29

Bony mets

Question 30

What would an increased calcium indicate?

Answer 30

Could indicate myeloma or bony mets

Question 31

What would an abnormal PSA indicate?

Answer 31

Bony mets originating from prostate cancer

Question 32

What are the options for imaging of back pain?

Answer 32

Radiographs (X-rays) CT scans MRI

Question 33

Pros/cons X-rays for back pain

Answer 33

Poor sensitivity, radiation Cheap, widely available

Question 34

Pros/cons CT

Answer 34

Good for bony pathology Larger radiation dose

Question 35

Pros/cons MRI

Answer 35

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 36

What are the key points about diagnostic imaging in low back pain

Answer 36

Radiographs have negligible value in assessment of back pain CT is an adjunct in a few cases MRI is main modality Low back pain is non-specific until further investigated

Question 37

70 year old woman Acute onset thoracic spine pain with radiation through to the chest wall Focally tender over thoracic spine Does she need investigation?

Answer 37

Thoracic pain, elderly is red flag Acute onset is odd

Question 38

What does this x-ray show?

Answer 38

Question 39

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 Does he need investigation? Differential diagnosis?

Answer 39

Weight loss night sweats –infection-tb? Could be cancer, less likely in 25yrold-lymphoma in young ppl? morning stiffness - characteristic of ankylosing spondylitis

Question 40

What does this show?

Answer 40

T1: L4/5 endplate destruction. Soft tissue mass encroaching spinal canal T2: altered signal in sacral segments Have spinal tb with paraspinal absess- eating away at disc and spine

Question 41

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 Does he need imaging? Likely diagnosis?

Answer 41

Doesnt need imaging cos no red flags Mechanical back pain with sciatica-slipped disc-touching nerve root –shooting pain

Question 42

Outline the natural history and treatment for herniated discs

Answer 42

Most prevalent in individuals aged 30-50 Good outlook Normally spontaneous improvement, although typically slower than for low back pain alone Treatment: 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

Question 43

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 Does she need imaging? Likely diagnosis?

Answer 43

Prolonged morning stiffness is red flag- so need imaging so ankylosing spondylitis

Question 44

Briefly outline the pathophysiology of ankylosing spondylitis

Answer 44

Ankylosing spondylitis (AS) is a disease linked to inflammation where tendons and ligaments attach to bones (enthesitis). It has a strong genetic component, particularly the HLA-B27 gene, which is found in most AS patients but not everyone with HLA-B27 develops the disease. Key immune factors like TNF-alpha, IL-17, and IL-23 contribute to its development. **No need to know background for exam just need to know HLA is a marker for ankyjwnbf spodhuewhf**

Question 45

How is ankylosing spondylitis managed?

Answer 45

Physiotherapy and a life-long regular exercise programme Pharmacological 1st line: non-steroidal anti-inflammatory drugs (NSAIDs) -e.g. ibuprofen, naproxen, diclofenac 2nd line: ‘Biological’ therapies Therapeutic monoclonal antibodies (mAbs) targeting specific molecules