1b// Back Pain Flashcards
1
Q
What are the 3 functions of the spine?
A
Locomotor: capable of being both rigid & mobile
Bony armour: protects the spinal cord
Neurological: spinal cord transmission of signals between brain & periphery
2
Q
How is the spine split up anatomically?
A
Cervical (normal kyphosis)
thoracic (normal kyphosis)
lumbar (normal lordosis)
3
Q
Kyphosis vs Lordosis
A
Kyphosis – A rounding of the spine in the upper back. It can look like you have a hump in your back. Lordosis – An increased curve toward the front of your body in your lower back or neck area
4
Q
How many vertebrae are there, and how many in C, T and L?
A
24 bones
7 C
12 T
5 L
5
Q
What are intervertebral discs?
A
shock absorbers, allow segmentation & multi-directional movement
6
Q
What are facet joints?
A
small synovial joints at posterior spinal column linking each vertebra
7
Q
What do muscles do for the spine?
A
move the spine
8
Q
Where is lumbar puncture performed and why?
A
lumbar puncture is performed at L3/4 space to avoid spinal cord
9
Q
What does the spinal cord do and where does it end?
A
transmission of signals to/from brain. Ends at L2 vertebra
10
Q
Where do nerve roots exit and how?
A
exit the spinal cord bilaterally
11
Q
What is the cauda equina?
A
nerve bundle
12
Q
What are the movements of the spine?
A
Flexion (forward bend) vs extension (backward bend)
Lateral flexion (side bend)
Rotation (twist)
13
Q
How common is back pain?
A
more than 50% of people will experience an episode
14
Q
Which type of back pain is self-limiting?
A
acute back pain (gets better by itself)
most better in a few days, 96% are better in 6 weeks
15
Q
What defines a chronic back pain?
A
longer than 12 weeks durations
16
Q
Is chronic back pain common?
A
yes due to sedentary lifestyle
17
Q
What do you NEED to distinguish when it comes to back pain?
A
distinguish mechanical back pain from serious pathology
18
Q
What are common causes of mechanical back pain? (4)
A
-Muscular tension (e.g. chronic poor posture, weak muscles)
-Acute muscle sprain/spasm
-Degenerative disc disease (more common in elderly)
-Osteoarthritis of facet joints (more common in elderly)
19
Q
What are the 2 features of mechanical back pain?
A
reproduced or worse with movement
better or not present at rest
20
Q
What may accompany mechanical back pain?
A
sciatica
21
Q
What is sciatica?
A
nerve pain radiating down one leg
22
Q
What is sciatica typically due to?
A
disc herniation (slipped disc) contacting the exiting lumbar nerve root
23
Q
What determines the location of the pain in sciatica?
A
determined by the level of the herniated disc
24
Q
What is happening here?
A
sciatica
there is a tear in the annulus fibrosus allowing the nerve root to be contacted by nucleus pulposus
25
What is the type of pain experienced an a certain area by sciatica?
pins and needles, burning in area
Sometimes it feels like a jolt or electric shock. It can be worse when coughing or sneezing or sitting a long time. Usually, sciatica affects only one side of the body. Some people also have numbness, tingling, or muscle weakness in the leg or foot (google)
26
What are serious causes of back pain? (6)
Tumour
Infection
Inflammation spondyloarthropathy
Fracture
Large disc prolapse
NB referred pain
27
What type of tumour can cause back pain?
metastatic cancer or myeloma
28
What type of infection can cause back pain? (3)
Discitis
Vertebral osteomyelitis
Paraspinal abscess
Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)
29
Which type of bacteria is quicker, and which one takes weeks for the serious pain to set in, in back pain?
staphylococcus and streptococcus are quicker
Mycobacterium Tuberculosis takes weeks
30
What can cause inflammatory spondyloarthropathy? (3)
ankylosing spondylitis
psoriatic arthritis
inflammatory bowel disease (IBD)-associated (e.g., Chron's)
31
What type of fractures can lead to back pain?
traumatic or atraumatic
32
What do large disc prolapse cause?
neurological compromise
33
What can lead to referred pain of back pain?
pancreas, kidneys, aortic aneurysm
34
What are the red flags for back pain? (10)
- pain at night or increased pain when supine
- constant or progressive pain
- thoracic pain
- weight loss
- previous malignancy
- Fever/ night sweats
- immunosuppressed
- Bladder or bowel disturbance (sphincter dysfunction)
- leg weakness or sensory loss
- age <20 or >55 yrs
35
What is a neurosurgical emergency?
cauda equina syndrome
36
What can happen if cauda equina syndrome is left untreated?
permanent lower limb paralysis and incontinence
37
What are the symptoms/ signs of cauda equina syndrome? (5)
Saddle anaesthesia
Bladder/bowel incontinence
Loss of anal tone on PR
Radicular leg pain
Ankle jerks may be absent
38
What are the investigations for cauda equina syndrome?
urgent MRI L spine
39
What are the causes of cauda equina syndrome? (5)
large disc herniation, bony mets, myeloma, TB, paraspinal abscess
40
What is the treatment for cauda equina syndrome?
according to cause: may require urgent surgery
41
What do you take for history taking of back pain?
SOCRATES
* Prolonged morning stiffness
* Effect of movement vs. inactivity**
* Buttock pain
* Leg weakness
* Sensory loss/paraesthesia
* Lower limb claudication
42
How do you examine the spine in a primar care setting?
Look
Feel
Move
Straight leg raise (SLR)
Lower limb neurological exam
General exam (signs of malignancy, AAA)
43
What is the straight leg raise for?
for sciatica
if pins and needles it is a positive sign for sciatica
44
Where do you palpate for an AAA?
abdomen
abdominal aortic aneurysm
45
When should you (not) investigate back pain?
In the absence of red flags, investigation usually not required
46
What should you not do to diagnose non-specific low back pain in primary care?
Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care
47
What should you do if symptoms persist or worsen after 3-4 weeks?
Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause
48
What are the treatments for lower back pain without red flags?
Time
Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
AVOID bed rest: keep moving
Physiotherapy
-Soft tissue work
-Corrective exercises esp. core
49
What blood tests should you do for back pain?
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
FBC
alkaline phosphatase (ALP)
calcium
PSA (prostate specific antigen)
50
When does ESR (erythrocyte sedimentation rate) increase?
↑ in myeloma, chronic inflammation, TB
51
In which condition is ESR increased but CRP normal?
myeloma
52
When is CRP increased?
↑ in infection or inflammation
53
What can you find out from FBC for back pain?
anaemia in myeloma, chronic disease. ↑ WCC in infection
54
When does alkaline phosphatase increase?
↑ with bony metastases (mets)
55
When can calcium increase?
may be ↑ in myeloma, bony metastases (mets)
56
When can PSA (prostate specific antigen) increase?
prostate
Ca with bony mets
57
What are the types of imaging you can perform?
radiographs (x-ray)
computer tomography (CT)
magnetic resonance imaging (MRI)
58
What are the pros/ cons of radiographs (x-rays)?
-poor sensitivity, radiation -cheap, widely available
59
What are the pros and cons of CTs?
-good for bony pathology, larger radiation dose
60
What are the pros and cons of 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
61
* 70 year old woman
* Acute onset thoracic spine pain with radiation through to the chest wall
* Focally tender over thoracic spine
Does she need investigations?
Yes bc thoracic and 55 y/o
62
* 70 year old woman
* Acute onset thoracic spine pain with radiation through to the chest wall
* Focally tender over thoracic spine
What is the diagnosis?
Osteoporotic vertebral collapse “Wedge fracture”
63
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?
yes, weight loss and night sweats
Tb, malignancy
64
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
What is the diagnosis?
TB w/ paraspinal abscess
65
A 45-year-old man complains of acute back pain and sciatica extending down the R leg into the foot associated with paresthesia
No incontinence of bladder/bowel Examination: no weakness, sensation intact
He has been off work for two weeks and wants to know when he can get back to work
Does he need imaging? Likely diagnosis?
No
sciatica
66
In who are herniated discs most prevalent with?
30-50 y/o
67
How do herniated discs improve?
Normally spontaneous improvement, although typically slower than for low back pain alone
68
What is the treatment for herniated discs?
1. Conservative as for LBP without sciatica
-Analgesia especially NSAIDs
-Physiotherapy to improve core strength and treat associated muscle spasm
2. Nerve root injection (local anaesthetic and glucocorticoid)
3. Surgery if neurological compromise or symptoms persist
69
Is surgery beneficial for herniated disc?
Trials of surgery vs conservative Rx show no long term advance for surgery
70
* 25 year old woman
* Presents with 1 year history of lumbar and buttock pain, with morning stiffness lasting 2 hours
* Ibuprofen helps
* Examination: reduced range of L spine movements
Does she need imaging? Likely diagnosis?
Yes and blood tests
ankylosing spondylitis
71
What is SpA?
Inflammatory Spondyloarthritis
72
What are Inflammatory Spondyloarthritis?
group of immune mediated inflammatory diseases
ankylosing spondylitis (AS), psoriatic arthritis, inflammatory bowel disease (IBD)
73
What is primarily the inflammation of Inflammatory Spondyloarthritis?
of the spine (spondylitis)
and sacro-iliac joints (sacro-iliiitis)
74
What else can be affected by Inflammatory Spondyloarthritis?
Peripheral joints, esp. tendon insertions (entheses), can also be affected
75
What are extra-articular manifestations of Inflammatory Spondyloarthritis (SpA)?
AAAA
Anterior uveitis (iritis) – ocular inflammation
Apical lung fibrosis
Aortitis/aortic regurgitation
Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
76
What do you lose from the spine due to ankylosing spondylitis?
loss of movement
77
What is the pathophysiology of ankylosing spondylitis?
Characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)
78
Is ankylosing spondylitis genetic?
Large genetic component
Many genetic variants associated with the disease (polygenic)
HLA-B27 is the strongest genetic risk factor
HLA-B27 +ve in 90% of AS patients versus ~10% in general population
79
What is the background of HLA?
HLA = a region on chromosome 6 encoding MHC molecules
HLA-B27 is a class 1 MHC molecule
Cells present peptides to CD8 T cells in association with MHC class 1 molecules
80
What is used as a diagnostic biomarker for ankylosing spondylitis?
HLA-B27 Used as a diagnostic biomarker but HLA-B27 +ve alone does not equal AS
81
What else play an important role in pathogenesis of ankylosing spondylitis?
Cytokines play important roles in pathogenesis
tumour necrosis factor alpha (TNF-alpha) interleukin-17 (IL-17)
interleukin-23 (IL23)
Aberrant peptide processing pathways (aminopeptidases) in the endoplasmic reticulum
82
What is this?
83
What is the natural history of untreated ankylosing spondylitis?
Spinal enthesitis
->
Bridging syndesmophytes
(new bone growth between adjacent vertebra) ->
Spinal fusion
84
What can you see in a spinal MRI of ankylosing spondylitis?
MRI can detect spinal inflammation before X-rays changes develop
“Shiny corners” sign at L4, L5 and S1
85
What is the management of ankylosing spondylitis?
1) Physiotherapy and a life-long regular exercise programme
2) pharmacological
2.1. 1st line NSAIDs
2.2. 2nd line biological therapies
86
What is the 1st line of pharmacological treatment for AS?
1st line: non-steroidal anti-inflammatory drugs (NSAIDs)
-e.g. ibuprofen, naproxen, diclofenac
-Mechanism: NSAIDs inhibit cyclooxygenase 1 and 2 (COX1 and 2)
-Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk
-Selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk
87
What is the 2nd line of pharmacological treatment for AS?
2ndline: ‘Biological’ therapies
Therapeutic monoclonal antibodies (mAbs) targeting specific molecules
Use if inadequate disease control after trying 2 NSAIDs
Anti-TNF-alpha (e.g. adalimumab, certolizumab, infliximab, golimumab)
Anti-IL17 (e.g. secukinumab)
