1b Back Pain Flashcards
What are the three main functions of the spine?
- Locomotior
- Body Armour
- Neurological
How many vertabrae is the spinal column made up from?
7 Cervical
12 Thoracic
5 Lumbar
24 total
What is the purpose of the intervertebral discs?
shock absorbers, allow segmentation & multi-directional movement
What are facet joints?
small synovial joints at posterior spinal column linking each vertabrae
What is lordosis?
Normal curvature of the lower spine
what is kyphosis?
The outward curve of the thoracic spine
At what level does the cauda equina form?
L2
At what level is a lumbar puncture performed?
L3/4 to avoid spinal cord damage
What are the two components of the intervertebral disc?
Nucleus pulposus
Annulus fibrosus
What are the three movements of the spine?
Flexion
Lateral flexion - side bend
Rotation (twist)
What are the three types of back pain?
Mechanical
Non-specific
nerve root back pain
How does mechanical back pain change with movement?
Reproduced or worse with movement
What are the common causes of back pain?
Muscular tension
Acute muscle sprain
Degenerative disc disease
OA of facet joints
What causes sciatica?
Disc herniation (slipped disc) which then comes into contact with the exiting lumbar nerve root
What determines the location of the pain of disc herniation?
The level at which the disc herniation occurs, and which dermatome this corresponds to
What are the more serious causes of back pain?
Tumour - Metastatic cancer or Myeloma (malignancy of plasma cells)
Infection - Discitis and Vertebral Osteomyelitis
Inflammatory Spondyloarthropathy
Fracture
Large disc prolapse
What infective condition can commonly cause back pain?
TB - insidious onset
What are the red flag criteria of back pain?
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
What are the symptoms of cause equina syndrome?
Saddle anaesthesia
Bladder/bowel incontinence
Loss of anal tone on PR
Radicular leg pain
Ankle jerks may be absent
What causes cauda equina syndrome?
When the nerves which run lower than L1 are compressed
If untreated, what does cauda equina syndrome lead to?
permanent lower limb paralysis and incontinence
What investigation is done for Cauda Equina syndrome?
urgent MRI of Lower spine
In which situation is investigations not usually required?
in the absense of red flags
What is the treatment for lower back pain without red flags?
Time
Analgesia
Keep moving
Physio - soft tissue work and corrective exercises
In which conditions would ESR be raised?
↑ in myeloma, chronic inflammation, TB
In which conditions would CRP be raised?
Infection or inflammation
In which conditions would ALP be raised?
↑ with bony metastases (mets)
Which conditions could a FBC provide some information on?
anaemia in myeloma, chronic disease.
↑ WCC in infection
In which condition might calcium be raised
may be ↑ in myeloma, bony metastases (mets)
Which is the best imagine technique for bony pathologies?
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
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?
Thoracic = red flag so yes
Diagnosis = wedge fracture
What is a wedge fracture?
A compression fracture of the spinal column in which the front side of the spine collapses, resulting in a wedge shape
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?
T1: L4/5 endplate destruction. Soft tissue mass encroaching spinal canal
T2: altered signal in sacral segments
What are the three treatment options for herniated discs?
- Conservativ eg NSAIDs
- Nerve root injections
- Surgery
For herniated discs what is included in the nerve root injection which is often given to settle down the irritation?
local anaesthetic and glucocorticoid(steroids)
What is inflammatory spondyloarthritis?
Primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis)
Peripheral joints, esp. tendon insertions (entheses), can also be affected
What are the four extra-articular manifestations of Inflammatory SpA? (A’s)
Anterior uveitis (iritis) – ocular inflammation
Apical lung fibrosis
Aortitis/aortic regurgitation
Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
What effect does ankylosing spondylitis have on the spine?
Loss of spinal movements
What is the pathophysiology of ankylosing spondylitis?
Characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)
What is the strongest genetic risk factor for ankylosing spondylitis?
HLA-B27 = encodes class 1 MHC molecules
What three cytokines play an important role in the pathogenesis of ankylosing spondylitis?
tumour necrosis factor alpha (TNF-alpha)
interleukin-17 (IL-17)
interleukin-23 (IL23)
What is the natural progression of ankylosing spondylitis?
Spinal enthesitis
->
Bridging syndesmophytes
(new bone growth between adjacent vertebra)
->
Spinal fusion
What is seen on an MRI of the spine in a patient with ankylosing spondylitis?
Shiny corners sign
What is the first line pharmacological treatment for ankylosing spondylitis?
NSAID’s eg ibuprofen etc
How do NSAID’s work in the treatment of ankylosing spondylitis?
NSAIDs inhibit cyclooxygenase 1 and 2 (COX1 and 2) meaning no prostaglandin production, therefore less inflammation and pain
What are the risks of using NSAID’s to treat ankylosing spondylitis?
-Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk
How can the risks associated with using NSAID;s for spondylitis be reduced?
Use selective COX2 inhibitors to reduce the GI risk
What are the two main biological therapies used in the treatment of ankylosing spondylitis?
Anti-TNF-alpha (e.g. adalimumab, certolizumab, infliximab, golimumab)
Anti-IL17 (e.g. secukinumab)
