Flashcards in Orthopedics Deck (105)
What is non specific low back pain?
Tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg
What is radicular pain?
Pain caused by irritation or compression of nerve roots
Typically pain/numbness in a dermatomal distribution
Describe the epidemiology of low back pain
Annual incidence of first episode: 6%-15%
Annual incidence of any episode: 1% - 36%
Lifetime prevalence: Estimates up to 84%
Name some specific causes of low back pain
Inflammatory disorders: ankylosing spondylitis
Cauda equina compression
Non-spinal causes of back pain
How common is infection as a cause of low back pain? And how would you go about diagnosing it?
Where is the lower back?
Area bounded by the bottom of the 12th ribs, the buttock creases and the mid-axillary line
What investigations would you do in a patient that you suspected had an infective cause for their lower back pain?
Imaging, blood count, inflammatory markers
In whom are osteoporotic fractures a more likely cause of their lower back pain?
Older people, female, low body mass, taking glucocorticoids, past history of fragility fracture, Cushing's syndrome, alcohol intake, smoking, regular falls
How do you diagnose osteoporosis?
Measure bone mineral density using a DEXA scan
Normal: t score >-1
What is the specific treatment for osteoporosis? What is the mechanism of action?
Bisphosphonates: encourage osteoclasts to undergo apoptosis so reducing bone resorption
Examples: alendronate, risendronate, zoledronic acid
What are the most common malignancies which may present as lower back pain?
Primary: Myeloma, Intra-abdominal disease
Metastatic disease: Breast, Prostate, Lung
What malignant cause of back pain do you suspect in a patient who presents with >60, back pain, weight loss + other abdominal symptom or new onset diabetes?
What malignancy might you suspect in a patient who presents as >60 with persistent back pain?
What investigations would you do for a patient who you suspect has multiple myeloma?
Bloods; FBC, Calcium, Plasma viscosity/ESR
What investigation would you do for a patient with suspected pancreatic cancer as a cause of their back pain?
Urgent direct access CT
What are the nice guidelines on patients with cancer with back pain in whom you should act urgently (
Pain in the thoracic or cervical spine
Progressive lumbar spinal pain
Severe unremitting lower spinal pain
Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)
Localised spinal tenderness
Nocturnal spinal pain preventing sleep
How does Ankylosing spondylitis typically present?
Relieved by exercise
What are extra articular symptoms of Ankylosing spondylitis?
Uveitis: inflammation of uvea, pigmented layer between inner retina and outer fibrous layer of sclera and cornea
Enthesitis: inflammation of the entheses, sites where tendons or ligaments insert into bone
What might you see on an X-ray of an Ankylosing spondylitis spine?
Bamboo spine: vertebral body fusion by marginal syndesmophytes
Typically involves thoracolumbar and/or lumbosacral junctions and predisposes to unstable vertebral fractures
Outer fibres of annulus fibrosis of IV discs ossify which results in the formation of the syndesmophytes between adjoining vertebral bodies
What is inflammatory back pain?
Chronic back pain >3 months
Onset of symptoms before age 45 yrs
Back pain at night
Morning stiffness (>30 mins)
Improvement with exercise
When should you consider Ankylosing spondylitis as opposed to inflammatory back pain?
If several factors present together:
Inflammatory back pain
Alternating buttock pain
Response to NSAIDs
Onset of symptoms before age 45
Peripheral disease manifestations (arthritis, dactylitis, enthesitis)
Confirmed acute anterior uveitis
Positive family history
Sacroiliitis/spondylitis by imaging
What is cauda equina syndrome and what key symptoms would you ask a patient about?
Compression of nerve roots below level of spinal cord termination: caused by central disc prolapse, tumour
Weakness / numbness in legs
Bowel or bladder dysfunction
Saddle / perineal anaesthesia
What is the nice guidance on suspected cauda equina
compression in people with cancer?
Immediate referral metastatic spinal cord compression co-ordinator if: neurological symptoms including radicular pain,
any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
Name some non spinal causes of low back pain
Abdominal aortic aneurysm
Pancreatitis / pancreatic cancer
Renal pain (stone/infection)
Gynaecological disorders: fibroids
List some red flags which you want to ask about in a patient presenting with lower back pain
Lower extremity neurological deficit
What is Lasègue's sign?
Straight leg raise: determine whether patient with low back pain has a herniated disk, often at L5
Patient experiences sciatic pain when straight leg raised between 30 and 70 degrees
What is Kernig test?
Thigh flexed at the hip, knee at 90 degrees
Subsequent extension in knee is painful and often resisted
May indicate sub arachnoid haemorrhage or meningitis
What is bragards test?
Used to determine whether a source of lower back pain is nervous or muscular
Straight leg raise is done, if positive, leg lowered just below point of pain and then ankle is dorsiflexed
If pain increases, pain is likely nervous in origin
If no increase in pain, source is likely muscular
When is imaging of spine needed for low back pain?
Investigation for specific cause of back pain: Metastatic Disease, Bloods may be more appropriate and easier to organise
When surgery is being considered: Suspected cauda equina compression - Immediate, Radicular pain that is not resolving, To identify those with operable lesions congruent with symptoms, Selected patients who might be considered for spinal fusion