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msk + rheum > 1B back pain > Flashcards

1B back pain Flashcards

1
Q

What is the function 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

What are key MSK structures?

A
  • Spinal column
  • Muscles
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3
Q

What is the spinal column made of?

A
  • Vertebrae
    • 24 bones
    • 7 cervical
    • 12 thoracic
    • 5 lumbar
  • Intervertebral discs
  • Facet joints
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4
Q

What functions do intervertebral discs have?

A
  • Shock absorbers
  • Segmentation + multi-directional movement
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5
Q

What are facet joints?

A

Small synovial joints at posterior spinal column linking each vertebra

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6
Q

What are key neurological structures?

A
  • Spinal cord
  • Nerve roots
  • Cauda equina
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7
Q

What is the function of the spinal cord?

A

Transmission of signals to/from brain.

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8
Q

When does the spinal cord end?

A

L2 vertebra

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9
Q

Where is a lumbar puncture performed?

A

At L3/4 space to avoid spinal cord

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10
Q

How do spinal nerve roots end?

A

Exit spinal cord bilaterally

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11
Q

What is the cauda equina?

A

Nerve bundle

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12
Q

What movements does the spine allow for?

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

Very common: >50% of people will experience an episode.

Most will be better in a few days, 96% better in six weeks.

Acute back pain is usually self-limiting.

Chronic back pain (>12 weeks duration) is also common due to sedentary lifestyle.

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14
Q

How can back pain be categorised?

A
  • Mechanical back pain
  • Serious pathology
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15
Q

How is mechanical back pain distinguished?

A
  • Reproduced or worse with movement
  • Better or not present at rest
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16
Q

What are some causes of mechanical back pain?

A
  • Muscular tension (e.g. chronic poor posture, weak muscles)
  • Acute muscle sprain/spasm
  • Degenerative disc disease
  • Osteoarthritis of facet joints
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17
Q

What may mechanical back pain be accompanied by?

A

Sciatica (pain radiating down one leg)

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18
Q

What is sciatica usually caused by?

A

Typically due to disc herniation (slipped disc) contacting the exiting lumbar nerve root.

The location of the pain is determined by the level of the herniated disc.

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19
Q

What are some serious causes of back pain?

A
  • Tumour
  • Infection
  • Inflammatory spondyloarthropathy
  • Fracture (traumatic or atraumatic)
  • Large disc prolapse (causing neurological compromise)
  • Referred pain (pancreas, kidneys, aortic aneurysm)
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20
Q

What tumours can cause serious back pain?

A

Metastatic cancer, myeloma

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21
Q

What infections can cause back pain?

A
  • Discitis
  • Vertebral osteomyelitis
  • Paraspinal abscess
  • Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)
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22
Q

What inflammatory spondyloarthropathy cause back pain?

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • inflammatory bowel disease (IBD)-associated
23
Q

What are red flag symptoms of back pain?

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
24
Q

What is cauda equina syndrome?

A

Neurosurgical emergency
If left untreated= permanent lower limb paralysis and incontinence

25
Q

What are the symptoms of cauda equina syndrome?

A
  • Saddle anaesthesia
  • Bladder/bowel incontinence
  • Loss of anal tone on PR
  • Radicular leg pain
  • Ankle jerks may be absent
26
Q

What investigation is done for cauda equina syndrome?

A

Urgent MRI L spine

27
Q

What causes cauda equina syndrome?

A
  • large disc herniation
  • bony mets
  • myeloma
  • TB
  • paraspinal abcess
28
Q

What treatment is done for cauda equina syndrome?

A

According to cause: may require urgent surgery

29
Q

What needs to be considered when taking history for back pain?

A
  • Site & pattern
  • Onset
  • Character (e.g. aching, throbbing, burning, electricity)
  • Radiation (e.g. sciatica)
  • Associated symptoms
    • Prolonged morning stiffness
    • Effect of movement vs. inactivity
    • Buttock pain
    • Leg weakness
    • Sensory loss/paraesthesia
    • Lower limb claudication
  • Exacerbating/relieving factors
30
Q

How is the spine examined?

A
  • Look
  • Feel
  • Move
  • Straight Leg Raise (SLR)
  • Lower limb neurological exam
  • General exam (malignancy, AAA)
31
Q

What are the NICE guidelines to investigating back pain without red flags?

A
  • In the absence of red flags, investigation usually not required
  • Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care
  • Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause
32
Q

What is the treatment for low 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
33
Q

What blood tests are done for back pain?

A
  • ESR
  • CRP
  • FBC
  • ALP
  • Ca2+
  • PSA
34
Q

Fill in this table

A
35
Q

What imaging is offered for back pain?

A
  • Radiography (X-Ray)
  • CT
  • MRI
36
Q

Pros and cons of CT?

A
  • good for bony pathology
  • but larger radiation dose
37
Q

Pros and cons of MRI?

A
  • Best visualisation of soft tissue structures like tendons and ligaments
  • Best for spinal imaging: can see spinal cord and exiting nerve roots
  • But expensive and time-consuming
38
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”

39
Q

What’s the prognosis of herniated discs?

A
  • Good outlook
  • Normally spontaneous improvement, although typically slower than for low back pain alone
40
Q

What’s the treatment for herniated discs?

A

Treatment:
1. Conservative as for LBP without sciatica
- Analgesia especially NSAIDs
- Physiotherapy to improve core strength and treat associated muscle spasm

  1. Nerve root injection (local anaesthetic and glucocorticoid)
  2. Surgery if neurological compromise or symptoms persist

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

41
Q

What does this show?

A

Spontaneous resolution of prolapsed lumbar disc

Sequential MRI studies reveal that the herniated portion of the disc tends to regress with time, with partial or complete resolution in two thirds of cases after six months.

42
Q

What is inflammatory spondyloarthritis (SpA)?

A
  • Group of immune-mediated inflammatory diseases
  • Ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD)
43
Q

What does SpA affect?

A
  • Primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis)
  • Peripheral joints, esp. tendon insertions (entheses), can also be affected
44
Q

What are extra-articular manifestations of SpA?

A
  • Anterior uveitis (iritis) – ocular inflammation
  • Apical lung fibrosis
  • Aortitis/aortic regurgitation
  • Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
45
Q

What is ankylosing spondylitis?

A

Loss of spinal movements

46
Q

What is ankylosing spondylitis characterised by?

A

Enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)

47
Q

Explain the pathophysiology of ankylosing spondylitis

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
  • Used as a diagnostic biomarker but HLA-B27 +ve alone does not equal AS
  • Cytokines play important roles in pathogenesis:
  • Aberrant peptide processing pathways (aminopeptidases) in the endoplasmic reticulum
48
Q

What cytokines play important roles in pathogenesis of AS?

A
  • tumour necrosis factor alpha (TNF-alpha)
  • interleukin-17 (IL-17)
  • interleukin-23 (IL23)
49
Q

What occurs in untreated AS?

A

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

50
Q

What imaging is used for ankylosing spondylitis?

A

Spinal MRI as MRI can detect spinal inflammation before X-rays changes develop.

Imaging shows “shiny corners” sign at L4, L5 and S1

51
Q

Explain the management of ankylosing spondylitis

A

1) Physiotherapy and life-long regular exercise programme
2) Pharmacological

52
Q

What is the pharmacological first line treatment for AS and what is the mechanism?

A

NSAIDs (e.g. ibuprofen, naproxen, diclofenac)

Mechanism: NDSIds inhibit COX1 and 2

53
Q

What are the risks of NSAIDs and how is the risk reduced?

A
  • Peptic ulcer
  • Renal
  • Asthma exacerbation
  • ↑ atherothrombosis risk

Selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk

54
Q

What is the pharmacological second line treatment of AS?

A
  • 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)

msk + rheum (5 decks)

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