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

WEEK 3 - MINI LECTURES - LBP Flashcards

1
Q

Prevalence of LBP

A
  • 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%
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2
Q

Functional spinal unit

A
  • 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
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3
Q

End plate driven disc degeneration

A
  • associated with endplate defects
  • upper lumbar and thoracic spine
  • higher heritability
  • occurs before afe 30
  • moderate pain
  • caused by spinal compression
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4
Q

Annulus driven intervertebral disc degeneration

A
  • associated with annulus fissure
  • lower lumbar spine
  • lower heritability
  • rarely before age 30
  • strong association with pain
  • caused by spinal bending
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5
Q

Red flags for back pain

A
  • 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
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6
Q

If red flags present, what do you order?

A
  • plain radiograph
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7
Q

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

A
  • MRI
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8
Q

If MRI is contraindicated or not available

A

CT

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9
Q
  • suspected bony metastses or multifocal infection
A
  • Bone scan
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10
Q

Sciatica/radiculopathy: do we do imaging?

A
  • no, unless pain not improving or the neurological deficit is progressing
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11
Q

Possible cord or cauda equina compression - imaging?

A
  • yes, urgent imaging required -> MRI
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12
Q

Possible spinal canal stenosis - imaging?

A
  • only if indicated
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13
Q

Epidural space

A
  • between dura and surrounding vertebral canal

- contains fat, loose connective tissue, small arteries, veins, lymphatics

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14
Q

Subdural space

A
  • potential space between dura, outer surface of arachnoid
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15
Q

Subarachnoid space

A
  • between inner surface of arachnoid and Pia
  • contains CSF, vessels, spinal cord ligaments, nerves, filum etrminale
  • continuous with intrachranial SAS
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16
Q

Extradural compartment

A
  • epidural space

- vertebral bodies, neural arches, intervertebral discs, muscles

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17
Q

Intradular extramedullary compartment

A
  • SAS
  • spinal cord ligaments
  • nerve roots
  • cauda equina
  • filum terminale
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18
Q

Imtramedullary compartment

A
  • spinal cord,

Pia

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19
Q

Treating non-specific LBP

A
  • conservatively
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20
Q

Sciatica/canal stenosis

A
  • initially conservative

- then surgical

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21
Q

Acute non-specific LBP

- first line care

A
  • advice
  • simple analgesics
  • review
22
Q

Acute non-specific LBP

- second line care

A
  • Medicines: compound analgesics, NSAIDS, muscle relaxant, opioids
  • Physical therapies: spinal manipulation, heat wrap therapy
23
Q

Persistent non-specific LBP

A

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

24
Q

STarT back approach

A
  • triage
  • physio directs care
  • standardised physiotherapy, minimal treatment, advice, medicatin
25
Q

BioPsychoSocial model to treat back pain

A
  • Bio: range of motion, strength, endurance
  • psycho: emotions, beliefs, distress
  • Social: sick role, culture, family, work situation
26
Q

MPS model vs usual care

A
  • additional benefits for pain
  • additional benefits for disability
  • no difference for work
27
Q

BPS vs physical treatment

A
  • additional benefit for pain
  • additional benefit for disability
  • additional benefit for work
28
Q

Surgical options for non-specific LBP

A
  • 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
Q

Causes of sciatica (2 common causes)

A
  • acute disc protusion

- chronic degenerative lumbar spine stenosis (in older patient)

30
Q

Surgical options for sciatica

A
  • discectomy

- laminectomy (remove lamina or posterior spinal process)

31
Q

Evidence for surgery for acute disc protrusion

A
  • short term benefit to surgery but no difference in long term
32
Q

Evidence for surgery for Lumbar spine stenosis

A
  • poor evidence to support surgery or to distinguish between surgical alternatives
33
Q

Injection therapy for back and leg pain

A
  • commonly performed for LBP
  • commonly performed for sciatica
  • usually corticosteroids and local anesthetic
34
Q

Different routes of injection for back and leg pain

A
  • central epidural
  • facet joint
  • transforaminal
  • disc space
35
Q

Evidence for injection therapy

A
  • no long term benefit over placebo
  • small shrot term benefit over placebo
  • no advatage of any one method
  • no benefit in any diagnosis
36
Q

Cancer redflags

A
  • history of cancer
  • age over 50
  • unexplaiend weight lost
  • failure to improve after 1 months
  • nocturnal pain
37
Q

Cancers causing back pain

A
  • cancers that metastasize to bone: lung, breast, prostate, thyroid, kidney
  • rarer: leukemia, lymphoma, myeloma
38
Q

Infection red flags

A
  • NOT ALWAYS FEVER
  • underlying medical conditions: diabetes, coronary heart disease, immunosuppressive disorders
  • cancer
  • renal failure
  • IV drug use
39
Q

Diagnosis and management of infection as a cause of back pain

A
  • 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
Q

Fracture as a cause of back pain red flags

A
  • diagnose with X ray or technetium bone scan
  • red flags: prolonged use of steroids, age > 70, trauma
  • most common redflag condition
41
Q

Cauda equina syndrome red flags

A
  • dysfunction of bladder, bowel or sexual function

- sensory changes in saddle or perianal area

42
Q

Cauda equina syndrome: causes

A
  • degenerative disc/spinal disease
  • tumours
  • infection
  • trauma
  • investigation by MRI
43
Q

Treatment of cauda equina syndrome

A
  • urgent surgical decompression
44
Q

4 kinds of spondyloarthropathy

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • reactive arthritis
  • enteropathic arthritis
45
Q

AS epidemiology

A
  • 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
Q

AS clinical features

A
  • 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
Q

AS extraspinal features

A
  • peripheral arthritis in 35-50%

- large joints: hips, knees, shoulders, ankles

48
Q

Extra articular features continued

A
  • inflammatory eye disease
  • inflammatory bowel disease
  • lung disease
  • aortic valve disease
  • psoriasis
49
Q

Investigations for AS

A
  • 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
Q

Management of AS

A
  • exercise
  • education
  • NSAIDS
  • TNF-inhibitors
51
Q

BAck pain and return to work

A
  • 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

Block 2 - MSK (38 decks)

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