WEEK 3 - MINI LECTURES - LBP Flashcards Preview

Block 2 - MSK > WEEK 3 - MINI LECTURES - LBP > Flashcards

Flashcards in WEEK 3 - MINI LECTURES - LBP Deck (51):
1

Prevalence of LBP

- 1/5 of global population
- 1 months: 30 %
- lifetime: 40%

- less than 2/3 will recover
- 1/2 will have recurrence in next year

- peaks at about 50%

2

Functional spinal unit

- nucleus - loss of PG/calcification
- Annulus: fissures/ tears/ nerve ingrowth
- subchondral bone: sclerosis, increased BMD, inflammation, schmorl's nodes
- Nucleus extrusion: cord compression, radiculopathy
- Facet joint OA
- supra and interspinous ligament
- all injuries are related

3

End plate driven disc degeneration

- associated with endplate defects
- upper lumbar and thoracic spine
- higher heritability
- occurs before afe 30
- moderate pain
- caused by spinal compression

4

Annulus driven intervertebral disc degeneration

- associated with annulus fissure
- lower lumbar spine
- lower heritability
- rarely before age 30
- strong association with pain
- caused by spinal bending

5

Red flags for back pain

- constitutional symptoms
- immunosuppression
- history of malignancy or unexplained weight loss
- trauma
- prolonged use of corticosteroids
- osteoporosis
- neurological signs and symptms
- failure to improve after 4-6 weeks

6

If red flags present, what do you order?

- plain radiograph

7

If after the radiograph the cause of back pain is still uncertain

- MRI

8

If MRI is contraindicated or not available

CT

9

- suspected bony metastses or multifocal infection

- Bone scan

10

Sciatica/radiculopathy: do we do imaging?

- no, unless pain not improving or the neurological deficit is progressing

11

Possible cord or cauda equina compression - imaging?

- yes, urgent imaging required -> MRI

12

Possible spinal canal stenosis - imaging?

- only if indicated

13

Epidural space

- between dura and surrounding vertebral canal
- contains fat, loose connective tissue, small arteries, veins, lymphatics

14

Subdural space

- potential space between dura, outer surface of arachnoid

15

Subarachnoid space

- between inner surface of arachnoid and Pia
- contains CSF, vessels, spinal cord ligaments, nerves, filum etrminale
- continuous with intrachranial SAS

16

Extradural compartment

- epidural space
- vertebral bodies, neural arches, intervertebral discs, muscles

17

Intradular extramedullary compartment

- SAS
- spinal cord ligaments
- nerve roots
- cauda equina
- filum terminale

18

Imtramedullary compartment

- spinal cord,
Pia

19

Treating non-specific LBP

- conservatively

20

Sciatica/canal stenosis

- initially conservative
- then surgical

21

Acute non-specific LBP
- first line care

- advice
- simple analgesics
- review

22

Acute non-specific LBP
- second line care

- Medicines: compound analgesics, NSAIDS, muscle relaxant, opioids

- Physical therapies: spinal manipulation, heat wrap therapy

23

Persistent non-specific LBP

1) advice + simple analgesic
2) Complex medicine, physical therapy, psychological therapy
3) multidisciplinary pain clinic

24

STarT back approach

- triage
- physio directs care
- standardised physiotherapy, minimal treatment, advice, medicatin

25

BioPsychoSocial model to treat back pain

- Bio: range of motion, strength, endurance

- psycho: emotions, beliefs, distress

- Social: sick role, culture, family, work situation

26

MPS model vs usual care

- additional benefits for pain
- additional benefits for disability
- no difference for work

27

BPS vs physical treatment

- additional benefit for pain
- additional benefit for disability
- additional benefit for work

28

Surgical options for non-specific LBP

- fusion of two vertebrae together on one or more levels. Evidence suggest it is no better than structured alternative treatments

- disc replacement: evidence of mild benefit over fusion

29

Causes of sciatica (2 common causes)

- acute disc protusion
- chronic degenerative lumbar spine stenosis (in older patient)

30

Surgical options for sciatica

- discectomy
- laminectomy (remove lamina or posterior spinal process)

31

Evidence for surgery for acute disc protrusion

- short term benefit to surgery but no difference in long term

32

Evidence for surgery for Lumbar spine stenosis

- poor evidence to support surgery or to distinguish between surgical alternatives

33

Injection therapy for back and leg pain

- commonly performed for LBP
- commonly performed for sciatica
- usually corticosteroids and local anesthetic

34

Different routes of injection for back and leg pain

- central epidural
- facet joint
- transforaminal
- disc space

35

Evidence for injection therapy

- no long term benefit over placebo
- small shrot term benefit over placebo
- no advatage of any one method
- no benefit in any diagnosis

36

Cancer redflags

- history of cancer
- age over 50
- unexplaiend weight lost
- failure to improve after 1 months
- nocturnal pain

37

Cancers causing back pain

- cancers that metastasize to bone: lung, breast, prostate, thyroid, kidney

- rarer: leukemia, lymphoma, myeloma

38

Infection red flags

- NOT ALWAYS FEVER
- underlying medical conditions: diabetes, coronary heart disease, immunosuppressive disorders
- cancer
- renal failure
- IV drug use

39

Diagnosis and management of infection as a cause of back pain

- most common organism is staph aureus, followed by E coli
- aspirate and send for culture before antibiotics
- treatment is antibiotic for 3 months, and surgical decpompression if neurological function is compromised
- MRI sensitivity: 90%

40

Fracture as a cause of back pain red flags

- diagnose with X ray or technetium bone scan
- red flags: prolonged use of steroids, age > 70, trauma

- most common redflag condition

41

Cauda equina syndrome red flags

- dysfunction of bladder, bowel or sexual function
- sensory changes in saddle or perianal area

42

Cauda equina syndrome: causes

- degenerative disc/spinal disease
- tumours
- infection
- trauma

- investigation by MRI

43

Treatment of cauda equina syndrome

- urgent surgical decompression

44

4 kinds of spondyloarthropathy

- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis

45

AS epidemiology

- Prevalence is 0.1-1.4%
- Male:Female is 3:1
- Peak age onset: 20-30 years
- affects spine and peripheral joints
- 75% present with back symptoms
- sacroiliitis - required for diagnosis
- inflammation occurs at enthesis

46

AS clinical features

- inflammatory back pain
- buttock pain - sacroiliitis
- fatigue, weight loss
- loss of lumbar lordosis
- reduced back movements
- pain on stressing sacroiliac joints
- reduced chest expansion
- bamboo spine

47

AS extraspinal features

- peripheral arthritis in 35-50%
- large joints: hips, knees, shoulders, ankles

48

Extra articular features continued

- inflammatory eye disease
- inflammatory bowel disease
- lung disease
- aortic valve disease
- psoriasis

49

Investigations for AS

- Hb, WCC and platelets normal
- ESR, CRP elevated especially if peripheral arthritis
- Xrays - sacroiliac joints and spine is essential
- syndesmophytes present
- HLA-B27 antigen

50

Management of AS

- exercise
- education
- NSAIDS
- TNF-inhibitors

51

BAck pain and return to work

- varies between and within countries
- depends on workers compensation insurance system
- vast majority will return to work
- 5-10% will not return to work after 12 months
- determinants are predominantly psychosocial