OA

Question 1

List 8 causes of low back pain

Answer 1

Facet joint OA

Disc degeneration

Disc herniation

Inflammatory back pain

Fractures

Malignancy

Infection

Intra-abdominal pathology

Question 2

What are the 2 types of disc herniation seen in low back pain and what are the possible complications of these?

Answer 2

Central: can cause canal stenosis

Posterolateral: can cause radicular impingement

Question 3

List 3 causes of inflammatory back pain

Answer 3

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis/Reiter’s syndrome (term not used much anymore)

Question 4

Why is it important to investigate the cause of lower back fractures?

Answer 4

May be due to osteoporosis, malignancy or trauma

Question 5

What malignancies commonly metastasise to bone and how are these classified?

Answer 5

Osteolytic (common): breast, lung, thyroid, renal, adrenal, GI

Osteosclerotic: prostate, TCC

Mixed: breast, lung, prostate

Question 6

List 3 infectious causes of low back pain

Answer 6

Discitis

Osteomyelitis

Epidural abscess

Question 7

List 3 intra-abdominal pathologies which can cause low back pain

Answer 7

AAA

Renal pathology

Pelvic pathologies

Question 8

What is the usual anatomical cause of spinal canal stenosis resulting in radiculopathy?

Answer 8

Combination of:

Facet joint OA (narrowing of disc space, formation of osteophytes)

Ligamentum flavum hypertrophy

Bulging or thinning of intervertebral disc, resulting in herniation

NB It is thought that these changes result in impedance of venous outflow and arterial inflow, causing nerve root ischaemia and pain

Question 9

What clinical syndrome does lower (L4/5) spinal canal stenosis cause? Why?

Answer 9

Lumbar claudication

Due to compression of nerve roots

Question 10

What are the hallmark features of lumbar claudication?

Answer 10

Lumbar, buttock or thigh pain

Usually uni- but may be bi-lateral

Not present at rest

Comes on with exercise at a reproducible walking distance

Question 11

Given that degenerative changes in the lumbar spine are common beyond a certain age and not diagnostic, what MRI changes in the lumbar spine are more common in patients with back pain?

Answer 11

Disc bulge (most often seen, but seen frequently in those without back pain)

Disc protrusion (can also be commonly seen without back pain)

Disc extrusion (rarely seen in those without back pain)

Question 12

When is a full neurological examination warranted in a patient with lower back pain?

Answer 12

In the presence of lower limb pain and other neurological symptoms

Question 13

How reliable and valid are clinical signs detected during physical and psychosocial examination?

Answer 13

Interpret with caution

Question 14

What ancillary investigations are not routinely recommended in a patient with acute non-specific lower back pain?

Answer 14

Plain X-rays of lumbar spine (of limited diagnostic value and give no benefits in physical function, pain or disability)

Question 15

List 4 features/risk factors an infectious cause of acute low back pain

Answer 15

Symptoms and signs of infection (e.g. fever)

Underlying disease process

Immunosuppression

Penetrating wound

Question 16

List 2 features/risk factors for fracture as a cause of acute low back pain

Answer 16

History of trauma

Minor trauma if >50 years, history of osteoporosis and taking corticosteroids, history of malignancy

Question 17

List 6 features/risk factors for tumour as a cause of acute low back pain

Answer 17

Past history of malignancy

Age >50 years

Failure to improve with treatment

Unexplained weight loss

Pain at multiple sites

Pain at rest or at night (pretty non-specific; can get this with advanced OA)

Question 18

What might the absence of aggravating features for acute low back pain indicate?

Answer 18

Aortic aneurysms

Question 19

What is the timeline for recovery for a patient with a short duration of low back pain?

Answer 19

Majority recover within 3/12 (often persistence of milder symptoms)

NB Recurrences are common

Question 20

What factors are associated with progression from acute to chronic low back pain?

Answer 20

Psychosocial and occupational factors (“yellow flags”; should be assessed early to facilitate intervention)

Question 21

What is the first line treatment for simple back pain, and OA hip and knee pain?

Answer 21

Paracetamol in regular divided doses to a maximum of 4 g/day

NB Not as effective as NSAIDs but lower risk of AEs

Question 22

What is the verdict on NSAID use in OA?

Answer 22

Short term may be useful; use where simple analgesia and non-pharmacological measures are ineffective

Early in its natural history OA is often inflammatory - late OA is usually not

Consider AEs, esp in elderly and those on concomitant Rx (careful BP and renal function monitoring indicated, consider prescribing alongside a PPI or COX-2 inhibitor)

Question 23

Mrs Ierino, 55 year old woman, presents with increasing pain in the R buttock and groin on walking; pain began about 2 years ago but was intermittent and not severe

In last few months the pain is present when walking and limits her ability to climb stairs

Pain radiates to lateral thigh

What are the key points in the Hx?

Answer 23

Age

Time frame (chronic)

Distribution of pain

Presence of any low back pain

Presence of neurological Sx (e.g. parasthesia, numbness)

Previous injury

FHx of arthritis

Question 24

What secondary problems can develop as a result of abnormal gait in hip OA?

Answer 24

Trochanteric bursitis

Gluteal tendonopathy

Question 25

Is it common for hip pain to refer posteriorly?

Answer 25

No; some patients with hip pain refer posteriorly but uncommonly

Question 26

What nerve roots are usually impinged in sciatica?

Answer 26

S1/S2 (posterior)

Question 27

What nerve roots are likely compressed if the patient has lateral thigh pain?

Answer 27

L4/L5

Question 28

What nerve roots are likely compressed if the patient has groin pain?

Answer 28

L1/L2

Question 29

Mrs Ierino's groin and thigh pain is worse with walking and better with rest; there is some associated lower back pain Has stopped walking any distance due to pain Paracetamol is helpful Reluctant to take NSAID as she had a gastric ulcer 2 years ago after taking diclofenac for pain PHx: HTN for 10 years treaed with indapamide 2.5mg daily, T2DM diagnosed 6 years ago, treated with metformin 500mg BD, bleeding gastric ulcer 2 years ago after using diclofenac FHx: mother had AMI at 62 SHx: married with 2 children and 1 grandchild, husband works fulltime in family dry-cleaning business What are the most common causes of mechanical low back pain?

Answer 29

Facet joint OA Disc degeneration Disc herniation: central (can cause stenosis) or posterolateral (can cause radicular impingement)

Question 30

Identify 3 common causes of mechanical lower back pain

Answer 30

Facet joint OA Disc degeneration Disc herniation (central or posterolateral)

Question 31

Mrs Ierino, 55 year old woman, presents with increasing pain in the R buttock and groin on walking (radiates to lateral thigh), better with rest (some associated lower back pain); pain began about 2 years ago but was intermittent and not severe In last few months the pain is present when walking and limits her ability to climb stairs; she has recently stopped walking any distance due to the pain Paracetamol is helpful but she is reluctant to take an NSAID as she had a gastric ulcer 2 years ago after taking diclofenac for back pain PHx: HTN for 10 years treated with indapamide 2.5mg daily, T2DM diagnosed 6 years ago treated with metform 500mg BD, bleeding gastric ulcer 2 years ago after using diclofenac FHx: mother had AMI at age 62 SHx: married with 2 children and 1 grandchild, husband works fulltime in family dry cleaning business What steps are involved in the hip and back examination for Mrs Ierino?

Answer 31

Hip: look (including gait, Trendelenberg test), feel for back or soft tissue tenderness and around the pelvic brim (one side may be elevated due to a leg length discrepancy or scoliosis), move through full ROM, always watch the patient performing functional movements (getting up on the couch, doing a log roll, etc) If groin pain also check for inguinal hernias Back: look (for posture, curvatures, scoliosis), feel for vertebral or paravertebral (muscle spasm) tenderness, move through flexion/extension/lateral flexion/rotation, special tests including straight leg raise and Schober's test

Question 32

What are the 3 "red flag" conditions?

Answer 32

Infection Fracture Malignancy

Question 33

How is Schober's test performed and how is it interpreted? What is it usually used for?

Answer 33

Place fingers 15cm apart on back starting from level of L4, ask patient to touch toes, check to see if the distance increases to \>20cm If \<20cm, suggests ankylosing spondylitis, OA or muscular spasm Mostly used to monitor ankylosing spondylitis over time

Question 34

What might a waddling gait suggest?

Answer 34

Proximal myopathy

Question 35

What is a positive straight leg raise and what nerve roots does the straight leg raise test?

Answer 35

Pain before 60 degrees of motion is a positive test Tests L5/S1 (sciatica)

Question 36

How is the Trendelenberg test interpreted?

Answer 36

If non-stance hip sags, the problem is with the stance side Usually indicates weakness of adductor muscles gluteus medius and minimus (although be careful with interpretation - may also be effort on part of patient to reduce pain)

Question 37

What movement is most affected and affected earliest in hip OA?

Answer 37

Internal rotation

Question 38

What factors result in the poor pain localisation and complex patterns of referred pain in back and hip pathology?

Question 39

List 6 signs of scoliosis

Answer 39

Question 40

How is scoliosis classified based on XR? How can imagining inform Mx?

Answer 40

Simple C or compound S shaped Radiologists calculated COB angle

Question 41

Mr Mohamed, a 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box DDx?

Answer 41

Muscle spasm/tear Disc herniation/bulge Fracture Infection (ask about Hx of IVDU) LIgamentous damage Inflammatory spondyloarthropathy

Question 42

What is this sign called? What pathological changes are seen on this XR? What kind of fracture can be detected with this XR view?

Answer 42

Summation shadows of 2 overlapping lumbar vertebrae in the oblique view plain XR are said to resemble the outline of a "scotty dog" This example shows some facet joint OA (aka degenerative changes), including joint space narrowing and sclerosis Fracture of pars interarticularis (spondylolysis) on both sides gives the scotty dog a collar and can cause spondylolisthesis (forward displacement of a vertebra, commonly L5)

Question 43

What is the difference between disc bulging and disc herniation?

Answer 43

Disc bulging: no tear or rupture of the anulus fibrosus but the disc protrudes into the spinal canal Disc herniation: nucleosus pulposus herniates through anulus fibrosus, resulting in pain and inflammation

Question 44

If a patient presents with likely inflammatory lower back pain, what additional questions should you ask?

Answer 44

When is it worse? Any buttock pain? (Seen in ankylosing spondylitis) Does the pain wake them from sleep? Any extra-articular manifestations (IBD can be associated with joint disorders, may get plantar fasciitis in ankylosing spondylitis, OA or reactive arthritis)

Question 45

Why is it important to ask about how soon after a possible injury that pain developed?

Answer 45

Acute onset may indicate fracture, acute disc injury or a muscular cause (although note that muscle pain can take 24 hrs to develop)

Question 46

Mr Mohamed, 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box; pain is in the centre of his lumbar spine and radiates to both buttocks but not legs Pain worse on standing and walking but better lying down; rated 5/10 at rest and 8/10 with movement Paracetamol not helpful Mechanical or inflammatory pain? What extra feature is important to elicit?

Answer 46

Sounds mechanical Good to know if the patient is hyper-mobile (any Hx of previous injury, evidence of joint laxity O/E)

Question 47

Mr Mohamed, 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box What other information would you like?

Answer 47

PHx of LBP (may indicate early wear and tear, possibility of spondyloarthropathies) Site, radiation, mechanical pattern of pain How soon after the precipitating event did the pain start? Other medical Hx: use of oral steroids (e.g. for asthma), IVDU, immunosuppression Neurological Sx

Question 48

Mr Mohamed, 25 year old refugee from Iraq (arrived 3 years ago), presents with 2/7 of lumbar back pain after lifting a heavy box; pain is in the centre of his lumbar spine and radiates to both buttocks but not legs Pain worse on standing and walking but better lying down; rated 5/10 at rest and 8/10 with movement Paracetamol not helpful No PHx of back pain Smoker 5-10 cigarettes/day (especially relevant in older age group, as lung cancer commonly metastasises to bone) SHx: married with 2 children O/E: BP 115/70, HR 72, temp 37.2, slight loss of lumbar lordosis but no scoliosis, exquisite tenderness in mid-paravertebral lumbar spine, reduction of all back movements, no abnormal neurological signs What do these examination findings suggest about the diagnosis? Further Ix? In what circumstances would you order prompt imaging? Mx?

Answer 48

Less likely to be infective or inflammatory (no fever) Likely acute muscle spasm, indicated by tenderness and reduction of ROM in all planes Ix: probably not necessary (acute back pain is usually self-limiting) but consider XR if persistent pain Prompt imaging if neurological or inflammatory/infective Sx Mx: ongoing activity and heat pillow, provide written materail about acute back pain, consider need for paracetamol, NSAIDs and physio referral if pain does not resolve

Question 49

Mx of acute lower back pain

Answer 49

Stay active: small beneficial effect on pain, rate of recovery and function compared to bed rest, reduces sick leave Heat wrap therapy: continuous low level heat wrap therapy in first 48 hrs reduces pain, stiffness and disability over the next 3-4 days (better than paracetamol, NSAIDs or placebo, but not routinely available in Aus) Patient information: should be "activity-focussed" NSAIDs: given in practice but conflicting evidence for their use and efficacy Muscle relaxants and spinal manipulation NOT recommended (conflicting evidence of benefit, risk of AEs)

Question 50

Mechanism of NSAIDs

Answer 50

COX 1 and 2 inhibition (unless selective)

Question 51

What is the risk with use of selective COX-2 inhibitors (e.g. celecoxib)? Possible mechanism? When *are* they recommended?

Answer 51

Increased risk of MI so CI in those with significant CV RFs May be due to pushing AA through to TA2 production, increasing platelet aggregation Recommended with PHx of bleeding ulcer in absence of other RFs

Question 52

What types of pain should be considered when asking about radiation of lower back pain?

Answer 52

Referred pain: MSK, visceral Radicular pain: nerve root irritation

Question 53

What is the relationship between ankylosing spondylitis and pulmonary function?

Answer 53

Restrictive lung disease may occur in patients in later stages, with costovertebral and costosternal involvement limiting chest expansion