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BRS MUSCULOSKELETAL > 1b// Back Pain > Flashcards

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

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2
Q

How is the spine split up anatomically?

A

Cervical (normal kyphosis)

thoracic (normal kyphosis)

lumbar (normal lordosis)

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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

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4
Q

How many vertebrae are there, and how many in C, T and L?

A

24 bones

7 C
12 T
5 L

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5
Q

What are intervertebral discs?

A

shock absorbers, allow segmentation & multi-directional movement

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6
Q

What are facet joints?

A

small synovial joints at posterior spinal column linking each vertebra

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7
Q

What do muscles do for the spine?

A

move the spine

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8
Q

Where is lumbar puncture performed and why?

A

lumbar puncture is performed at L3/4 space to avoid spinal cord

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9
Q

What does the spinal cord do and where does it end?

A

transmission of signals to/from brain. Ends at L2 vertebra

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10
Q

Where do nerve roots exit and how?

A

exit the spinal cord bilaterally

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11
Q

What is the cauda equina?

A

nerve bundle

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12
Q

What are the movements of the spine?

A

Flexion (forward bend) vs extension (backward bend)

Lateral flexion (side bend)

Rotation (twist)

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13
Q

How common is back pain?

A

more than 50% of people will experience an episode

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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

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15
Q

What defines a chronic back pain?

A

longer than 12 weeks durations

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16
Q

Is chronic back pain common?

A

yes due to sedentary lifestyle

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17
Q

What do you NEED to distinguish when it comes to back pain?

A

distinguish mechanical back pain from serious pathology

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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)

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19
Q

What are the 2 features of mechanical back pain?

A

reproduced or worse with movement

better or not present at rest

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20
Q

What may accompany mechanical back pain?

A

sciatica

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21
Q

What is sciatica?

A

nerve pain radiating down one leg

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22
Q

What is sciatica typically due to?

A

disc herniation (slipped disc) contacting the exiting lumbar nerve root

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23
Q

What determines the location of the pain in sciatica?

A

determined by the level of the herniated disc

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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

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25
Q

What is the type of pain experienced an a certain area by sciatica?

A

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)

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26
Q

What are serious causes of back pain? (6)

A

Tumour

Infection

Inflammation spondyloarthropathy

Fracture

Large disc prolapse

NB referred pain

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27
Q

What type of tumour can cause back pain?

A

metastatic cancer or myeloma

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28
Q

What type of infection can cause back pain? (3)

A

Discitis
Vertebral osteomyelitis
Paraspinal abscess

Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)

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29
Q

Which type of bacteria is quicker, and which one takes weeks for the serious pain to set in, in back pain?

A

staphylococcus and streptococcus are quicker

Mycobacterium Tuberculosis takes weeks

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30
Q

What can cause inflammatory spondyloarthropathy? (3)

A

ankylosing spondylitis

psoriatic arthritis

inflammatory bowel disease (IBD)-associated (e.g., Chron’s)

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31
Q

What type of fractures can lead to back pain?

A

traumatic or atraumatic

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32
Q

What do large disc prolapse cause?

A

neurological compromise

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33
Q

What can lead to referred pain of back pain?

A

pancreas, kidneys, aortic aneurysm

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34
Q

What are the red flags for back pain? (10)

A
  • 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
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35
Q

What is a neurosurgical emergency?

A

cauda equina syndrome

36
Q

What can happen if cauda equina syndrome is left untreated?

A

permanent lower limb paralysis and incontinence

37
Q

What are the symptoms/ signs of cauda equina syndrome? (5)

A

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

38
Q

What are the investigations for cauda equina syndrome?

A

urgent MRI L spine

39
Q

What are the causes of cauda equina syndrome? (5)

A

large disc herniation, bony mets, myeloma, TB, paraspinal abscess

40
Q

What is the treatment for cauda equina syndrome?

A

according to cause: may require urgent surgery

41
Q

What do you take for history taking of back pain?

A

SOCRATES

  • Prolonged morning stiffness
  • Effect of movement vs. inactivity**
  • Buttock pain
  • Leg weakness
  • Sensory loss/paraesthesia
  • Lower limb claudication
42
Q

How do you examine the spine in a primar care setting?

A

Look
Feel
Move

Straight leg raise (SLR)

Lower limb neurological exam

General exam (signs of malignancy, AAA)

43
Q

What is the straight leg raise for?

A

for sciatica

if pins and needles it is a positive sign for sciatica

44
Q

Where do you palpate for an AAA?

A

abdomen

abdominal aortic aneurysm

45
Q

When should you (not) investigate back pain?

A

In the absence of red flags, investigation usually not required

46
Q

What should you not do to diagnose non-specific low back pain in primary care?

A

Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care

47
Q

What should you do if symptoms persist or worsen after 3-4 weeks?

A

Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause

48
Q

What are the treatments for lower back pain without red flags?

A

Time

Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)

AVOID bed rest: keep moving

Physiotherapy
-Soft tissue work
-Corrective exercises esp. core

49
Q

What blood tests should you do for back pain?

A

Erythrocyte sedimentation rate (ESR)

C-reactive protein (CRP)

FBC

alkaline phosphatase (ALP)

calcium

PSA (prostate specific antigen)

50
Q

When does ESR (erythrocyte sedimentation rate) increase?

A

↑ in myeloma, chronic inflammation, TB

51
Q

In which condition is ESR increased but CRP normal?

A

myeloma

52
Q

When is CRP increased?

A

↑ in infection or inflammation

53
Q

What can you find out from FBC for back pain?

A

anaemia in myeloma, chronic disease. ↑ WCC in infection

54
Q

When does alkaline phosphatase increase?

A

↑ with bony metastases (mets)

55
Q

When can calcium increase?

A

may be ↑ in myeloma, bony metastases (mets)

56
Q

When can PSA (prostate specific antigen) increase?

A

prostate
Ca with bony mets

57
Q

What are the types of imaging you can perform?

A

radiographs (x-ray)

computer tomography (CT)

magnetic resonance imaging (MRI)

58
Q

What are the pros/ cons of radiographs (x-rays)?

A

-poor sensitivity, radiation -cheap, widely available

59
Q

What are the pros and cons of CTs?

A

-good for bony pathology, larger radiation dose

60
Q

What are the pros and cons of MRI?

A

-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
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 investigations?

A

Yes bc thoracic and 55 y/o

62
Q
  • 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?

A

Osteoporotic vertebral collapse “Wedge fracture”

63
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

yes, weight loss and night sweats

Tb, malignancy

64
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

What is the diagnosis?

A

TB w/ paraspinal abscess

65
Q

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?

A

No

sciatica

66
Q

In who are herniated discs most prevalent with?

A

30-50 y/o

67
Q

How do herniated discs improve?

A

Normally spontaneous improvement, although typically slower than for low back pain alone

68
Q

What is the treatment for herniated discs?

A
  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
Q

Is surgery beneficial for herniated disc?

A

Trials of surgery vs conservative Rx show no long term advance for surgery

70
Q
  • 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?

A

Yes and blood tests

ankylosing spondylitis

71
Q

What is SpA?

A

Inflammatory Spondyloarthritis

72
Q

What are Inflammatory Spondyloarthritis?

A

group of immune mediated inflammatory diseases

ankylosing spondylitis (AS), psoriatic arthritis, inflammatory bowel disease (IBD)

73
Q

What is primarily the inflammation of Inflammatory Spondyloarthritis?

A

of the spine (spondylitis)

and sacro-iliac joints (sacro-iliiitis)

74
Q

What else can be affected by Inflammatory Spondyloarthritis?

A

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

75
Q

What are extra-articular manifestations of Inflammatory Spondyloarthritis (SpA)?

A

AAAA

Anterior uveitis (iritis) – ocular inflammation

Apical lung fibrosis

Aortitis/aortic regurgitation

Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs

76
Q

What do you lose from the spine due to ankylosing spondylitis?

A

loss of movement

77
Q

What is the pathophysiology of ankylosing spondylitis?

A

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

78
Q

Is ankylosing spondylitis genetic?

A

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
Q

What is the background of HLA?

A

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
Q

What is used as a diagnostic biomarker for ankylosing spondylitis?

A

HLA-B27 Used as a diagnostic biomarker but HLA-B27 +ve alone does not equal AS

81
Q

What else play an important role in pathogenesis of ankylosing spondylitis?

A

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
Q

What is this?

A
83
Q

What is the natural history of untreated ankylosing spondylitis?

A

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

84
Q

What can you see in a spinal MRI of ankylosing spondylitis?

A

MRI can detect spinal inflammation before X-rays changes develop

“Shiny corners” sign at L4, L5 and S1

85
Q

What is the management of ankylosing spondylitis?

A

1) Physiotherapy and a life-long regular exercise programme

2) pharmacological

2.1. 1st line NSAIDs

2.2. 2nd line biological therapies

86
Q

What is the 1st line of pharmacological treatment for AS?

A

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
Q

What is the 2nd line of pharmacological treatment for AS?

A

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)

BRS MUSCULOSKELETAL (12 decks)

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