10. Back/neck pain Flashcards
Differentials for back/eck pain?
Vascular
AAA
Aortic dissection
Infective
Osteomyelitis
Spinal epidural abscess
Septic arthritis
Discitis
Inflammatory
Ankylosing spondylitis
RA
OA
Degenerative
Osteoprortic vertebral fractures
Osteoarthritis
Cervical spondylosis
Trauma
C-spine injury major trauma - see major trauma
Neoplastic
Myeloma inc pathological fractures
Metastasis - Neoplastic spinal cord compression
Neuro
Prolapsed disc
Sciatica
Cauda equina
Lumbar spinal stenosis
Myelopathy
GI/renal
Pyelonephritis
Kidney stones
Pancreatitis
History taking back pain?
HoPC: location, onset, relieving factors, aggrevating factors, ever get pain in any other bones? morning stiffness? night time pain?
red flags - weight loss, kidney stones, bladder and bowel changes eg unable to control OR retention, any change to sensation when you wipe down below? any weakness in legs? any change to sensation? fever? injuries recently?
MHx: if man over 65 - have you attended screening for AAA?, history of kidney stones? ever had a cancer diagnosis?
SHx: alcohol, smoking, ever injected recreational drugs?
examiantion back pain?
spine + neuro + abdo
red flags back pain?
Major trauma (spinal fracture)
Stiffness in the morning or with rest (ankylosing spondylitis)
Age under 40 (ankylosing spondylitis)
Gradual onset of progressive pain (ankylosing spondylitis or cancer)
Night pain (ankylosing spondylitis or cancer)
Age over 50 (cancer)
Weight loss (cancer)
Bilateral neurological motor or sensory symptoms (cauda equina)
Saddle anaesthesia (cauda equina)
Urinary retention or incontinence (cauda equina)
Faecal incontinence (cauda equina)
History of cancer with potential metastasis (cauda equina or spinal metastases)
Fever (spinal infection)
IV drug use (spinal infection)
THORACIC PAIN
How many of each vertebrae?
Think about meal times… 7am, 12pm, 5pm
Cervical - 7
thoracic - 12
Lumbar - 5
Sacrum (5, fused)
Coxyx (4, fused)
What tool can be used to stratify the risk of developing chronic back pain
StarT BAck tool
The tool helps assess the risk of a patient presenting with acute back pain developing chronic back pain. This helps guide the intensity of the initial interventions (e.g., referral for group exercises, physiotherapy and cognitive behavioural therapy).
It involves 9 questions that assess the patient’s function and psychological response to the back pain. It gives a:
Total score (out of 9)
Subscore on the 4 psychosocial questions (out of 4)
total score >3 = medium or high risk
subscore <3 low or medium, >3 is high risk
What is mechanical back pain
Mechanical low back pain refers to back pain that arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. This includes lumbosacral muscle strain, disk herniation, lumbar spondylosis, spondylolisthesis, spondylolysis, vertebral compression fractures, and acute or chronic traumatic injury.1 Repetitive trauma and overuse are common causes of chronic mechanical low back pain, which is often secondary to workplace injury.
Management of no-specific lower back pain?
low risk of chronic back pain:
Self-management
Education
Reassurance
Analgesia
Staying active and continuing to mobilise as tolerated
Additional stuff for medium or high risk:
Physiotherapy
Group exercise
Cognitive behavioural therapy
The NICE advise for analgesia:
1. NSAIDs (e.g., ibuprofen or naproxen) first-line
2. Codeine as an alternative
+ Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
Vascualr causes of back pain?
AAA rupture
Aortic dissection
What is an AAA
An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta greater than 3cm in diameter.
At diameters greater than 5cm there is a significant risk of rupture and this event is life threatening and treated as a time critical medical emergency.
Pathophysiology AAA
The underlying cause of a AAA is usually atherosclerotic disease and there is a clear pathophysiological process from aneurysm formation to rupture:
- lipid deposition
- inflammation damages internal and external elastic laminae of the aortic wall
- loss of elastic laminae = difficulty with pressure change from diastole to systole –> dilation
- fibrosis
- aortic wall weaker then systolic pressure –> rupture
(therefore made much worse with HTN)
Features of a ruptured AAA? time course?
Pain - back/loin/ abdo going to back
CVS failure due to haemorrhage - tachycardia, hypotension, may have tamponade features if posterior rupture
Distal ischaemia - haematoma within aneyrysm –> embolise –> distal artery occlusion eg lower limb ischaemia
Death -
Approximately 33% of patients will die at the time of rupture and it should always be kept in mind as a differential for sudden death in middle age. Without treatment all AAA ruptures will eventually lead to death and it can be considered a terminal event.
test to diagnose ruptured AAA or rule it out
USS
can be performed by the bedside and gives an instant objective measurement of aortic diameter
tests to plan treatment once a ruptured AAA is diagnosed
Once a AAA has been diagnosed (eg USS) or known AAA patient has been admitted with a suspected rupture, the required investigations are used to plan treatment
The gold-standard imaging is a CT angiogram as this allows for a three-dimensional picture of the aneurysm to be created and this can be used to plan for surgery to repair it.
bloods
- FBC - ?low platelts which may require transfusion and affect surgical bleeding risk
- U&E - as if the aneurysm is treated endovascularly the patient will be exposed to large volumes of contrast and pre-existing renal failure may contraindicate this.
- Coagualtion screen
- A coagulation screen should be performed to ensure there is no underlying bleeding risk as during any vascular procedure intravenous heparin is used and the dose may need adjustment if there is a bleeding disorder.
- group and save and cross match
what does the chosen management of an AAA depend on? what are the options?
- Anatomy of the aneurysm
- Baseline health of the patient
- Clinical state of the patient on admission
Open surgical repair - GA, big surgery, risky for pts with significant cardiac disease
Endovascular aneurysm repair (EVAR) - local anaesthetic, only suitable for AAAs not involving the renal arteries, requires large quantities of radiological contrast and is therefore unsuitable for patients with significant renal impairment
Palliative -
Understanding that a ruptured AAA is a terminal event without treatment is important and it is valid to accept this and treat some patients palliatively with best supportive care.
clinical presentation (signif shock) or baseline physiological reserve might make this the only option
It is important to have adequate discussions with family members about the prognosis when patients present with a ruptured AAA, even if surgery is initially intended, as the condition can progress very quickly and become inoperable in a short period of time.
complications of AAA and of treatment for AAA
Acute limb ischaemia - esp in EVAR
Bowel ischaemia - Both open and endovascular repair require sacrifice or occlusion of the inferior mesenteric artery and this can lead to bowel ischaemia if the marginal arterial supply to the left colon is inadequate
Abdominal compartment syndrome - more common with open surgery
graft infection –> inadequate graft –> bleed
blood transfusion reactions
what does the screening program for AAA consist of?
Screening for an abdominal aortic aneurysm consists of a single abdominal ultrasound for males aged 65.
screening AAA outcome and action?
<3m = no further action
3 - 4.4cm = small aneurysm = resan every 12 mo
4.5-5.4 = medium aneurysm = rescna every 3mo
> 5.5cm = large aneurysm = rf to vasc surgery for probable intervention
ALSO OPTOMISE CVS RISKS
what constitutes a high risk AAA at screening? management?
symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)
treat with elective endovascular repair (EVAR) or open repair if unsuitable.
what is aortic dissection? pathophysiology?
Aortic dissection is a severe, life-threatening condition characterised by the separation of the aortic wall layers, resulting in the formation of a false lumen.
It frequently occurs due to an intimal tear, allowing blood to enter and dissect through the media layer. The aetiology often involves hypertension, connective tissue disorders (e.g., Marfan syndrome), or iatrogenic factors such as catheterization or cardiac surgery.
standford classification of aortic dissection
type A - ascending aorta, 2/3 of cases. (type A1 propagates to the aortic arch and sometimes beyond. type A2 is confined to ascending)
type B - descending aorta, distal to left subclavian origin, 1/3 of cases
presentation aortic dissection
sudden onset of severe chest pain radiating to the back
syncope, or neurological deficits.
Clinical presentation varies
invetsigation ?aortic dissection?
CT angiogram
management aortic dissection?
Management depends on the dissection type;
Type A requires emergent surgical intervention due to increased risk of complications like pericardial tamponade, myocardial ischemia, and aortic regurgitation.
surgical management, blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B dissections are primarily managed medically with strict blood pressure control unless exhibiting signs of malperfusion syndromes or impending rupture.
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
Associations aortic dissection
hypertension: the most important risk factor
trauma
bicuspid aortic valve
collagens: Marfan’s syndrome, Ehlers-Danlos syndrome
Turner’s and Noonan’s syndrome
pregnancy
syphilis
complications of aortic dissection
Complications of backward tear
aortic incompetence/regurgitation
MI: inferior pattern often seen due to right coronary involvement
Complications of forward tear
unequal arm pulses and BP
stroke
renal failure
what are the infective cuases of back pain?
septic arthritis
osteomyelitis
discitis
epidural abscess
what are the most commonly affected joints septic arthritis
hip, knee and ankle
typical history septic arthritis
PC: hot red swollen painful joint, stiffness and reduced range of motion, systemic symptoms such as fever and lethargy
any hot/red joint
most common causative organism septic arthritis ? other causes
staph aureus
Neisseria gonorrhoea (gonococcus) in sexually active teenagers
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
Escherichia coli (E. coli)
young pt presenting with single acutely swollen joint - first ddx?
always think of gonococcus septic arthritis until proven otherwise
Gonorrhoea infection is common and delaying treatment puts the joint in danger. In your exams it might say the gram stain revealed a “gram-negative diplococcus”. The patient may have urinary or genital symptoms to trick you into thinking of reactive arthritis but remember that it is important to exclude gonococcal septic arthritis first as this is the more serious condition.
plan ?septic arthritis
Have a low suspicion until joint fluid assessed
- Aspiration for gram stain, crystal microscopy, culture and antibiotic sensitivities
- If paeds, USS, if shows effusion and with corroborating history, treat as septic arthritis
- Bloods inflammatory markers, blood culture
- Empirical IV antibiotics (local guidelines)
- Continue abx for 3-6 weeks
Patients may require surgical drainage and washout of the joint to clear the infection in severe cases.
example first line regime septic arthritis abx
Flucloxacillin for 6 weeks
if pen allergic: clindamycin
If MRSA suspected: vancomycin
If gonococcal arthritis or gram -ve susepcted : cefotaxime or ceftriaxone
what criteria can be used in children to distinguish between septic arthritis and transient synovitis of hip
The kocher criteria
fever >38.5 degrees C
non-weight bearing
raised ESR > 40
raised WCC >12
If 0 = very unlikely and can be managed in primary care with close follow up
what is osteomyelitis
an infection in the bone and bone marrow.
This typically occurs in the metaphysis of the long bones.
what is the most common causative organism osteomyelitis
staph aureus
types of osteomyelitis and how do people get it?
Chronic osteomyelitis is a deep seated, slow growing infection with slowly developing symptoms.
Acute osteomyelitis presents more quickly with an acutely unwell pt.
The infection may be introduced directly into the bone, for example during an open fracture.
Alternatively it may have travelled to the bone through the blood, after entering the body through another route, such as the skin or gums.
In what children is osteomyelitis more common
boys and children under 10 years
typical history osteomyelitis
Osteomyelitis can present acutely with an unwell child, or more chronically with subtle features. Signs and symptoms are:
- Refusing to use the limb or weight bear
- Pain
- Swelling
- Tenderness
They may be afebrile, or may have a low grade fever. Children with acute osteomyelitis may have a high fever, particularly if it has spread to the joint causing septic arthritis.
best imaging for dx of osteomyelitis
MRI
initial invetsigation osteomyelitis
xray
plan investigation ?osteomyelitis
- xray
- MRI if xray inconclusive
- inflammatory markers CRP, ESR, WCC
- blood culture
management osteomyelitis
Osteomyelitis is treated with antibiotics, usually with surgical debridement
Flucloxacillin for 6 weeks
+ consider fusidic acid or rifmapicin
if pen allergic: clindamycin
If MRSA suspected: vancomycin
what is discitis
Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.
typical history discitis
Back pain
General features
pyrexia,
rigors
sepsis
Neurological features e.g. changing lower limb neurology if an epidural abscess develops
most common cause discitis
staph aureus
plan ?discitis
Invetsigation
Imaging: MRI has the highest sensitivity
blood culture
CT-guided biopsy may be required to guide antimicrobial treatment
transoesophageal/transthoracic echo to assess for endocarditis (seeding)
management
abx based on cultures/biopsy
what is a spinal epidural abscess?
A spinal epidural abscess (SEA) is a collection of pus that is superficial to the dura mater (of the meninges) that cover the spinal cord. It is an emergency requiring urgent investigation and treatment to avoid progressive spinal cord damage.
An abscess is a collection of pus encapsulated by a pyogenic membrane.
pathophysiology spinal epidural abscess
In SEA, bacteria enters the spinal epidural space by contiguous spread from adjacent structures (e.g. discitis), haematogenous spread from concomitant infection (e.g. bacteraemia from IVDU), or by direct infection (e.g. spinal surgery). Immunosuppression is another major risk factor, which may be caused by congenital immune disorders, acquired immune disorders (such as HIV, diabetes or alcoholism or by iatrogenic means (e.g. chemotherapy or steroids).
SEA is most typically bacterial and the most common causative micro-organism is Staphylococcus aureus.
Presentation spinal epidural abscess
fever
back pain
focal neurological deficits according to the segment of the cord affected.
invetsigations ?spinal epidural abscess
Investigations
Bloods (including inflammatory markers, HIV, Hep B, Hep C, and preoperative blood tests (coagulation and group and screen))
Blood cultures
Infection screen (including chest x-ray and urine culture)*
MRI whole spine (the entire spine is imaged since skip lesions may be present)
*If the primary source of infection is not clear, a wide search for sources requires investigations including echocardiography and dental x-rays.
management SEA
- empirical abx
- culture based abx
+ if compressive etc consider surgical evaluation
whata re some inflammatory cuases of back pain?
ankylosing spondylitis
scheurmann’s disease
typical history ankylosing spondylitis
PC: young man with lower back pain and stiffness of insidious onset, stiffness worse in the morning and improves with exercise. may experience pain at night which improves on getting up
what may you find on examination ank spond
- reduced lateral flexion
- reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
- reduced chest expansion
what gene is ank spond associated with ?
HLA B27
Investigation ank spond
- plain xray of sacroiliac joints
- if negative and still suspected, MRI
what may be found on xray in ank spond
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
why should you assess resp system in someone with ank spond, what might you find
at risk of apical fibrosis - request CXR if suspected
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
reduced chest expansion o/e
first line management ank spond
NSAIDs
Management ank spond
- NSAIDs
- Paracetamol/codeine if poorly tolerated
- Seek specialist advice
+ Physio
+ Hydrotherapy
+ OT
criteria for rheum referal ank spond
Refer to rheumatology for a spondyloarthritis assessment if a person has low back pain starting before the age of 45 years and lasting longer than 3 months, plus four or more of the following criteria:
Low back pain starting before the age of 35 years.
Symptoms which wake them during the second half of the night.
Buttock pain.
Improvement when moving.
Improvement within 48 hours of taking a nonsteroidal anti-inflammatory drug (NSAID).
Spondyloarthritis in a first-degree relative.
Current or past arthritis.
Current or past enthesitis.
Current or past psoriasis.
complications/associations ank spond
apical fibrosis
anterior uveitis
CVS risk and heart involvement: aortic regurg, AV node block
osteoporosis and fractures
cauda equina
what is scheuermann’s disease
epiphysitis of verterbral joints
This word describes a condition where the ends of the longer bones of the foal become swollen and painful. The ends of the bones are called the epiphyses, and itis means inflammation = epiphysitis.
what does anterior wedging mean - spinal imaging
When the vertebra crushes or collapses, it tends to collapse at the front. This is why compression fractures are sometimes known as anterior wedge fractures. As the bone at the front of the vertebra collapses, it forms a wedge shape.
presentation scheuermanns disease
progressive kyphosis (at least 3 vertebrae must be involved)
Symptoms include back pain and stiffness
management scheuermann’s disease
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
x-ray changes scheuermanns
epiphyseal plate disturbance and anterior wedging
what are fragility fractures?
Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray
Acute back pain
Breathing difficulties: changes in the shape and length of vertebrae lead to the compression of organs such as the lungs, heart and intestine
Gastrointestinal problems: due to compression of abdominal organs
Only a minority of patients will have a history of fall/trauma
risk factors osteoporotic fractures?
Advancing age is a major risk factor osteoporotic fractures: Women ≥ 65 years old and men ≥ 75 years old should be considered for fracture risk assessment. Women in this age bracket are almost certainly post-menopausal, therefore have reduced oestrogen levels - this is a risk factor for osteoporosis.
Previous history of a fragility fracture
Frequent or prolonged use of glucocorticoids
History of falls
Family history of hip fracture
Alternative causes of secondary osteoporosis e.g. Cushing’s disease, hyperthyroidism, chronic renal disease
Low BMI (< 18.5)
Tobacco smoking
High alcohol intake: > 14 units/week for women, > 21 units/week for men
where is (one of) the commonest sites of osteoporotic fragility frcatures to occur
the spine (vertebrae)
how do patients with osteoporotic vertebral fractures present?
Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray
Acute onset back pain
Breathing difficulties: changes in the shape and length of vertebrae lead to the compression of organs such as the lungs, heart and intestine
Gastrointestinal problems: due to compression of abdominal organs
Only a minority of patients will have a history of fall/trauma
o/e signs of osteoporotic vertebral fracture
Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter
Kyphosis (curvature of the spine)
Localised tenderness on palpation of spinous processes at the fracture site
first line investigation ?osteoprotic vertebral fracture
what does it show
X-ray of the spine
This should be the first investigation ordered and may show wedging of the vertebra due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a sclerotic appearance)
