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MUSCULOSKELETAL > 1b Back Pain > Flashcards

1b Back Pain Flashcards

1
Q

What are the three main functions of the spine?

A
  1. Locomotion - capable of both being mobile and standing up straight
  2. Body Armour - protecting the spinal cord
  3. Neurological - allows the transmission of electrical information from the BRAIN to the Periphery
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2
Q

How many vertabrae is the spinal column made up from?

A

7 Cervical
12 Thoracic
5 Lumbar

24 total

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3
Q

What is the purpose of the intervertebral discs?

A

shock absorbers, allow segmentation & multi-directional movement

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4
Q

What are facet joints?

A

small synovial joints at posterior spinal column linking each vertabrae

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5
Q

What is lordosis?

A

Normal curvature of the lower spine

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6
Q

what is kyphosis?

A

The outward curve of the thoracic spine

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7
Q

At what level does the cauda equina form?

A

L2

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8
Q

At what level is a lumbar puncture performed?

A

L3/4 to avoid spinal cord damage

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9
Q

What are the two components of the intervertebral disc?

A

Nucleus pulposus
Annulus fibrosus

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10
Q

What are the three movements of the spine?

A

Flexion
Lateral flexion - side bend
Rotation (twist)

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11
Q

What are the three types of back pain?

A

Mechanical
Non-specific
nerve root back pain

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12
Q

How does mechanical back pain change with movement?

A

Reproduced or worse with movement

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13
Q

What are the common causes of back pain?

A

Muscular tension
Acute muscle sprain
Degenerative disc disease
OA of facet joints

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14
Q

What causes sciatica?

A

Disc herniation (slipped disc) which then comes into contact with the exiting lumbar nerve root

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15
Q

What determines the location of the pain of disc herniation?

A

The level at which the disc herniation occurs, and which dermatome this corresponds to

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16
Q

What are the more serious causes of back pain?

A

Tumour - Metastatic cancer or Myeloma (malignancy of plasma cells)
Infection - Discitis and Vertebral Osteomyelitis
Inflammatory Spondyloarthropathy
Fracture
Large disc prolapse

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17
Q

What infective condition can commonly cause back pain?

A

TB - insidious onset

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18
Q

What are the red flag criteria of back pain?

A

Pain at night or increased pain when supine
Constant or progressive pain
Thoracic pain
Weight loss – may be a sign of cancer
Previous malignancy
Fever/night sweats
Immunosuppressed
Bladder or bowel disturbance (Sphincter dysfunction)
Leg weakness or sensory loss
Age <20 or >55 yrs

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19
Q

What are the symptoms of cause equina syndrome?

A

Saddle anaesthesia
Bladder/bowel incontinence
Loss of anal tone on PR
Radicular leg pain
Ankle jerks may be absent

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20
Q

What causes cauda equina syndrome?

A

When the nerves which run lower than L1 are compressed

21
Q

If untreated, what does cauda equina syndrome lead to?

A

permanent lower limb paralysis and incontinence

22
Q

What investigation is done for Cauda Equina syndrome?

A

urgent MRI of Lower spine

23
Q

In which situation is investigations not usually required?

A

in the absense of red flags

24
Q

What is the treatment for lower back pain without red flags?

A

Time
Analgesia
Keep moving
Physio - soft tissue work and corrective exercises

25
Q

In which conditions would ESR be raised?

A

↑ in myeloma, chronic inflammation, TB

26
Q

In which conditions would CRP be raised?

A

Infection or inflammation

27
Q

In which conditions would ALP be raised?

A

↑ with bony metastases (mets)

28
Q

Which conditions could a FBC provide some information on?

A

anaemia in myeloma, chronic disease.
↑ WCC in infection

29
Q

In which condition might calcium be raised

A

may be ↑ in myeloma, bony metastases (mets)

30
Q

Which is the best imagine technique for bony pathologies?

A

MRI

-Best visualization of soft tissue structures like tendons and ligaments
-Best for spinal imaging: can see spinal cord and exiting nerve roots
-Expensive and time-consuming

31
Q

70 year old woman
Acute onset thoracic spine pain with radiation through to the chest wall
Focally tender over thoracic spine
Does she need investigation?

A

Thoracic = red flag so yes
Diagnosis = wedge fracture

32
Q

What is a wedge fracture?

A

A compression fracture of the spinal column in which the front side of the spine collapses, resulting in a wedge shape

33
Q

25 year old man originally from Nepal
Worsening low back pain for 8 weeks
Worse in the morning but present at all times
Weight loss
Night sweats

Does he need investigation?
Differential diagnosis?

A

T1: L4/5 endplate destruction. Soft tissue mass encroaching spinal canal
T2: altered signal in sacral segments

34
Q

What are the three treatment options for herniated discs?

A
  1. Conservativ eg NSAIDs
  2. Nerve root injections
  3. Surgery
35
Q

For herniated discs what is included in the nerve root injection which is often given to settle down the irritation?

A

local anaesthetic and glucocorticoid(steroids)

36
Q

What is inflammatory spondyloarthritis?

A

Primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis)

Peripheral joints, esp. tendon insertions (entheses), can also be affected

37
Q

What are the four extra-articular manifestations of Inflammatory SpA? (A’s)

A

Anterior uveitis (iritis) – ocular inflammation
Apical lung fibrosis
Aortitis/aortic regurgitation
Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs

38
Q

What effect does ankylosing spondylitis have on the spine?

A

Loss of spinal movements

39
Q

What is the pathophysiology of ankylosing spondylitis?

A

Characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)

40
Q

What is the strongest genetic risk factor for ankylosing spondylitis?

A

HLA-B27 = encodes class 1 MHC molecules

41
Q

What three cytokines play an important role in the pathogenesis of ankylosing spondylitis?

A

tumour necrosis factor alpha (TNF-alpha)
interleukin-17 (IL-17)
interleukin-23 (IL23)

42
Q

What is the natural progression of ankylosing spondylitis?

A

Spinal enthesitis
->
Bridging syndesmophytes
(new bone growth between adjacent vertebra)
->
Spinal fusion

43
Q

What is seen on an MRI of the spine in a patient with ankylosing spondylitis?

A

Shiny corners sign

44
Q

What is the first line pharmacological treatment for ankylosing spondylitis?

A

NSAID’s eg ibuprofen etc

45
Q

How do NSAID’s work in the treatment of ankylosing spondylitis?

A

NSAIDs inhibit cyclooxygenase 1 and 2 (COX1 and 2) meaning no prostaglandin production, therefore less inflammation and pain

46
Q

What are the risks of using NSAID’s to treat ankylosing spondylitis?

A

-Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk

47
Q

How can the risks associated with using NSAID;s for spondylitis be reduced?

A

Use selective COX2 inhibitors to reduce the GI risk

48
Q

What are the two main biological therapies used in the treatment of ankylosing spondylitis?

A

Anti-TNF-alpha (e.g. adalimumab, certolizumab, infliximab, golimumab)
Anti-IL17 (e.g. secukinumab)

MUSCULOSKELETAL (13 decks)

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