Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 2 - BRS > 8.4 - Back pain > Flashcards

8.4 - Back pain Flashcards

1
Q

What are the functions of the spine? (3)

A
  • locomotor - capable of being both rigid and mobile
  • bony armour - protects the spinal cord
  • neurological - spinal cord transmission of signals between brain and periphery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the five parts of the spine?

A
  • cervical (C1-7) - normal lordosis
  • thoracic (T1-12) - normal kyphosis
  • lumbar (L1-5) - normal lordosis
  • sacral (S1-5)
  • coccyx (Co1-4)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the key MSK structures of the spine?

A
  • spinal column made up of:
    • vertebrae - 24 bones (7 cervical, 12 thoracic, 5 lumbar)
    • intervertebral discs - shock absorbers, allow segmentation and multi-directional movement
    • facet joints - small synovial joints at posterior spinal column linking each vertebra
  • muscles - move the spine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the key neurological structures of the spine?

A
  • spinal cord - transmission of signals to/from brain
    • ends at L2 vertebra
  • nerve roots - exit the spinal cord bilaterally
  • cauda equina - nerve bundle, runs distally
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Where are lumbar punctures done?

A

Lumbar puncture is performed at L3/4 space to avoid the spinal cord (which ends at L2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the movements of the spine? (3)

A
  • flexion (forward bend) vs extension (backward bend)
  • lateral flexion (side bend)
  • rotation (twist)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is back pain?

A
  • very common: >50% of people will experience an episode
  • acute back pain usually self-limiting (resolves by itself)
  • most better in a few days, 96% better in six weeks
  • chronic back pain (>12 weeks duration) also common - sedentary lifestyle
  • need to distinguish mechanical back pain from serious pathology
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is mechanical back pain?

A
  • reproduced or worse with movement
  • better or not present at rest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are some common causes of mechanical back pain? (4)

A
  • muscular tension (e.g. chronic poor posture, weak muscles)
  • acute muscle sprain/spasm
  • degenerative disc disease
  • osteoarthritis of facet joints
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is sciatica?

A
  • pain radiating down one leg
  • mechanical back pain may be accompanied by sciatica
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is sciatica typically caused by?

A
  • typically due to disc herniation (‘slipped disc’) contacting the exiting lumbar nerve root
  • tear in annulus fibrosis –> nucleus pulposus leaks out and can contact nerve root –> irritation and pain in corresponding dermatome
  • location of the pain determined by the level of the herniated disc
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are some serious causes of back pain? (5 + 1)

A
  • tumour - metastatic cancer or myeloma
  • infection - discitis, vertebral osteomyelitis, paraspinal abscess
  • inflammatory spondyloarthropathy - ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease (IBD)-associated
  • fracture - traumatic or atraumatic
  • large disc prolapse - causing neurological compromise
  • NB referred pain (pancreas, kidneys, aortic aneurysm)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the common causes of infection (microbiology) of the back that cause back pain? (3)

A
  • Staphylococcus (acute)
  • Streptococcus (acute)
  • tuberculosis (chronic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the red flag symptoms for back pain? (10)

A
  • pain at night or increased pain when supine
  • constant or progressive pain
  • thoracic pain (mechanical pain usually cervical/lumbar)
  • weight loss
  • previous malignancy
  • fever/night sweats
  • immunosuppressed
  • bladder or bowel disturbance (sphincter dysfunction)
  • leg weakness or sensory loss
  • age <20 or >55 years
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is cauda equina syndrome?

A
  • neurosurgical emergency
  • untreated –> permanent lower limb paralysis and incontinence
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A
  • saddle anaesthesia
  • bladder/bowel incontinence
  • loss of anal tone on PR
  • radicular leg pain (pain radiates to legs)
  • ankle jerks may be absent
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What investigation is done for cauda equina syndrome?

A

Urgent MRI L spine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

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

A
  • large disc herniation
  • bony metastases
  • myeloma
  • tuberculosis
  • paraspinal abscess
  • (anything that compresses cauda equina)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the treatment for cauda equina syndrome?

A

According to the cause - may require urgent surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What things do you ask about when taking a history for back pain? (7)

A
  • SOCRATES
  • prolonged morning stiffness?
  • effect of movement vs inactivity
  • buttock pain
  • leg weakness (/pain)
  • sensory loss/paraesthesia
  • lower limb claudication (peripheral vascular disease, spinal stenosis)
21
Q

What do we do when examining the spine? (6)

A
  • look
  • feel
  • move
  • straight leg test (SLR) - sciatica = pins and needles felt (tests lumbar nerve root related pain)
  • lower limb neurological exam
  • general exam (signs of malignancy, AAA)
22
Q

What do we do if there are no red flag symptoms of back pain?

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/worsen after 3-4 weeks and reassess for underlying cause
23
Q

What are the treatments for low back pain without red flags? (4)

A
  • time
  • analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
  • AVOID bed rest - keep moving
  • physiotherapy - soft tissue work, corrective exercises (especially core)
24
Q

What blood tests can be done for back pain, and what abnormalities can they show? (6)

A
  • erythrocyte sedimentation rate (ESR) - high in myeloma, chronic inflammation, TB
  • CRP - high in infection or inflammation
  • FBC - anaemia in myeloma + chronic disease, WCC in infection
  • alkaline phosphatase (ALP) - high with bony mets
  • calcium - may be high in myeloma, bone mets
  • PSA - prostate cancer with bony mets
25
Q

What imaging modalities can be used to investigate back pain? (3)

A
  • radiographs (X-rays)
  • computed tomography (CT)
  • magnetic resonance imaging (MRI) - best test for back
26
Q

What is a pro and a con of using radiographs (X-rays) for investigating back pain?

A
  • +: cheap, widely available
  • -: poor sensitivity, radiation
27
Q

What is a pro and a con of using CT scans for investigating back pain?

A
  • +: good for bony pathology
  • -: larger radiation dose than X-ray
28
Q

What are pros and a con of using MRIs for investigating back pain?

A
  • +: best visualisation of soft tissue structures like tendons and ligaments
  • +: best for spinal imaging - can see SC and exiting nerve roots
  • -: expensive and time-consuming, claustrophobic
29
Q

Back pain case 1:
- 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?
What is the diagnosis?

A

Yes as she has red-flag symptoms:

  • age 55+
  • thoracic pain
  • radiation to chest wall

Diagnosis: osteoporotic vertebral collapse ‘wedge fracture’

30
Q

What would you see on X-ray of osteoporotic vertebral collapse ‘wedge fracture’?

A

Affected vertebra is triangular/wedge-shaped instead of a usual rectangle

31
Q

Back pain case 2:
- 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?
What is the diagnosis?

A

Yes due to red-flag symptoms:

  • weight loss
  • night sweats
  • worsening pain

Diagnosis: TB with paraspinal abscess

32
Q

What might you see on MRI spine of TB with paraspinal abscess?

A
  • T1 (CSF black) - L4/5 endplate destruction, soft tissue mass encroaching spinal canal
  • T2 (CSF white) - altered signal in sacral segments
  • generally murky/gunky area of the MRI indicates paraspinal abscess
  • confirm with aspiration sample
33
Q

Back pain case 3:
- 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 investigation? What is his diagnosis?

A
  • no investigation required as no red-flag symptoms
  • diagnosis: herniated disc
34
Q

What is herniated disc natural history/outlook like?

A
  • most prevalent in 30-50y/o
  • good outlook
  • normally spontaneous improvement, although typically slower than for low back pain alone (without sciatica)
35
Q

What are the treatments for herniated disc? (3)

A
  • conservative as for lower back pain without sciatica
    • analgesia especially NSAIDs
    • physiotherapy to improve core strength and treat associated muscle spasm
  • nerve root injection (local anaesthetic and glucocorticoid) - CT-guided
  • surgery if neurological compromise or symptoms persist
    • trials of surgery vs conservative Rx show no long term advance/improvement for surgery
36
Q

What do sequential MRIs show about prolapsed lumbar disc?

A

Sequential MRI studies reveal that the herniated portion of the disc tends to regress with time, with partial or complete resolution in 2/3 of cases after 6 months

37
Q

Back pain case 4:
- 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? What is the likely diagnosis?

A
  • yes - MRI and potentially bloods
  • diagnosis: ankylosing spondylitis
    • prolonged morning stiffness
    • young
    • ibuprofen helps
    • reduced range of movement
38
Q

What is inflammatory spondyloarthritis (SpA)?

A
  • group of immune-mediated inflammatory diseases:
  • ankylosing spondylitis (AS), psoriatic arthritis or IBD-associated
  • primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis)
  • peripheral joints, especially tendon insertions (entheses) can also be affected
39
Q

What are the extra-articular manifestations of inflammatory spondyloarthritis? (4)

A
  • Anterior uveitis (iritis) - ocular inflammation
  • Apical lung fibrosis (top of lungs)
  • Aortitis/aortic regurgitation
  • Amyloidosis - due to chronically serum amyloid A (SAA) depositing in organs
40
Q

How does ankylosing spondylitis manifest?

A

Loss of spinal movements (stiff and flat lumbar spine, neck held in fixed flexion, loss of curve of back)

41
Q

What is ankylosing spondylitis characterised by?

A

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

42
Q

Describe the genetic component of the pathophysiology of ankylosing spondylitis.

A
  • large genetic component
  • many gene variants associated with the disease (polygenic)
  • HLA-B27 is the strongest genetic risk factor
  • HLA-B27 is positive in 90% of AS patients versus 10% in general population
  • used as a diagnostic biomarker but +ve HLA-B27 alone does not equal AS
43
Q

What cytokines play important roles in the pathophysiology of ankylosing spondylitis? (3)

A
  • tumour necrosis factor alpha (TNF-a) - targeted therapeutically
  • IL-17
  • IL-23
44
Q

What about peptide processing pathways is important in the pathophysiology of ankylosing spondylitis?

A

Aberrant peptide processing pathways (aminopeptidases) in the endoplasmic reticulum

45
Q

How can we see sacro-iliitis on an X-ray/MRI?

A

Increased whiteness around sacro-iliac joints show inflammation and bone marrow oedema (not seen in early disease)

46
Q

What is the natural history of untreated ankylosing spondylitis?

A

Spinal enthesitis –> bridging syndesmophytes (new bone growth between adjacent vertebra, joints ossified instead of gaps) –> spinal fusion (loss of spinal movements)

47
Q

Why do we use MRI in ankylosing spondylitis, and what would you see?

A
  • MRI can detect spinal inflammation before X-ray changes develop
  • ‘shiny corners’ sign at L4, L5 and S1 etc
48
Q

What is the management of ankylosing spondylitis?

A
  1. physiotherapy and a life-long regular exercise programme
  2. pharmacological:
  • 1st line: NSAIDs e.g. ibuprofen, naproxen, diclofenac
    • mechanism: inhibit COX1&2
    • risks: peptic ulcer, renal, asthma exacerbation, increased atherothrombosis risk
    • selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk (but not CV risk)
  • 2nd line: biological therapies - therapeutic monoclonal antibodies targeting specific molecules
    • use if inadequate disease control after trying 2 NSAIDs
    • anti-TNFalpha (e.g. adalimumab, certolizumab, infliximab, golimumab)
    • anti-IL17 (e.g. secukinumab)

Year 2 - BRS (84 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions