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Acute back pain Flashcards

1
Q

What are some red flag clues in the evaluation of low back pain?

A 
duration > 6 weeks
age <18 or >50
trauma
cancer
fever, chills, night sweats
weight loss
injection drug use
immunocompromised status
recent GU or GI procedure
night pain
unremitting pain
pain worsened by coughing, sitting or Valsalva manoeuvre
pain radiating below knee
incontinence
saddle anaesthesia
severe or rapidly progressive neurologic deficit
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2
Q

What are some of the risk factors of osteoporosis?

A 
early menopause
smoking history
alcohol history
steroid use
parent with a hip fracture
previous fracture
obesity
T1DM
osteogenesis imperfecta
malabsorption
chronic liver disease
chronic malnutrition
hypogonadism or premature menopause
female
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3
Q

What is osteoporosis?

A

a generalised skeletal disorder characterised by compromised bone strength and deterioration of bone quality, often leading to fragility fracture

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4
Q

How is osteoporosis formally diagnosed?

A

DXA scanning with a T score < -2.5 when determined by lowest calculation from lumbar spine, femoral neck, or total femur T-score, but if fragility fractures are present, this is a firm diagnosis of osteoporosis even without DXA

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5
Q

What are the possible treatment options for osteoporosis?

A 
increase weight bearing exercise
smoking cessation
reducing alcohol
oral calcium and vitamin D
bisphosphonates e.g. alendronic acid 70mg once weekly
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6
Q

What is a fragility fracture?

A

any fracture caused by a fall from standing height or less, known as low energy trauma due to abnormal bone

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7
Q

What is a Colles fracture?

A

“dinner fork” deformity - fracture of the distal radius and ulna with dorsal angulation, typically the result of a fall onto outstretched hand

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8
Q

What does a myeloma screen consist of?

A 
LDH
calcium (bone profile)
ESR
Urine Bence Jones protein
Immunoglobulins and protein electrophoresis
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9
Q

Describe the mechanism of action of bisphosphonates.

A
  • inhibit osteoclast resorption of bone: attach to hydroxyapatite binding sites on bony surfaces, when osteoclasts resorb this bone bisphosphonate impairs osteoclast ability to adhere to and resorb bone and promotes apoptosis
  • prevents osteocyte and osteoblast apoptosis
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10
Q

How do bisphosphonates need to be taken?

A

once a week, first thing in the morning, before breakfast or any other tablets, lots of water, sit upright for 30 minutes

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11
Q

What are the side effects of bisphosphonates?

A

nausea, heartburn, headache, tiredness, renal impairment
osteonecrosis of the jaw
oesophageal ulceration
atypical femoral fracture

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12
Q

What are some causes of non-specific back pain?

A

muscle spasm
muscle strain/sprain
ligamentous injury

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13
Q

Discuss the pathophysiology of osteoporosis.

A
  • bone mass decreases with age
  • when bone mass drops to critical level -> high fracture risk
  • imbalance of bone formation (osteoblasts) and resorption (osteoclasts) involving signalling factors e.g. TGFa and IGF
  • osteocytes which co-ordinate bone turnover are influenced by oestrogen and calcium
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14
Q

Who should be assessed for osteoporosis?

A

all women > 65 years
all men > 75 years
men and women > 50 with risk factors

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15
Q

What tools are used to predict risk of osteoporotic fracture in next 10 years?

A

FRAX

Qfracture

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16
Q

What are the causes of fragility fractures?

A

osteoporosis

osteopenia

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17
Q

What are common osteoporotic fractures?

A

vertebral fracture
femoral neck
distal radius

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18
Q

70mg alendronic acid PO once weekly is the mainstay treatment of osteoporosis. What is given if this can not be tolerated?

A

zolendronic acid 5mg annually IV

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19
Q

What is the main side effect of Zolendronic acid?

A

24-48hr flu-like illness

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20
Q

How does ankylosing spondylitis present?

A

lower back pain and stiffness of insidious onset that is worse in the morning and gets better with exercise - affects other large joints asymmetrically

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21
Q

What are the 5 extra-articular features associated with AS?

A 
atypical lung fibrosis
anterior uveitis
achilles tendonitis/plantar fasciitis
aortic regurgitation
amyloidosis
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22
Q

How is AS diagnosed?

A
  • Schober’s test: an increase between the fingers of <5cm indicates spinal stiffness
  • hip x-ray: sacroiliitis, erosion of corners of vertebral bodies (Romanus lesions), development of bony spurs (syndesmophytes), calcification of spinal ligaments (bamboo spine)
23
Q

What are the treatment options of AS?

A

physiotherapy, exercise and slow release NSAIDs

24
Q

Which conditions are associated with HLA-B27?

A 
seronegative spondyloarthropathy (lack of rheumatoid factor)
psoriatic arthritis
ankylosing spondylitis
IBD
reactive arthritis
25
What is multiple myeloma?
a multi-system disease that may present with lethargy, bone pain, pathological fracture, amyloidosis and pancytopenia due to marrow inflitration
26
How is a diagnosis of multiple myeloma made?
Two of the following: - marrow plasmacytosis - serum/urinary immunoglobulin light chains (Bence Jones protein) - skeletal lesions (osteolytic lesions, pepperpot skull, pathological fractures)
27
What are the symptoms of cervical spondylosis?
``` axial neck pain occipital pain tension headaches paraspinal stiffness reduced ROM ```
28
How do you treat cervical spondylosis?
physiotherapy NSAIDs benzodiazepines for spasms
29
Differentiate between acute and chronic radiculopathy.
Acute: lateral prolapse of a disc compresses a nerve root Chronic: osteophytic encroachment of the intervertebral foramina
30
What are the symptoms of radiculopathy?
neck pain radiating in the distribution of the affected nerve root - unilateral, shooting, electrical in nature numbness and tingling in distribution of affected root may report reduced strength in certain movements
31
What are some lower motor neuron lesion signs?
``` paresis fibrillations fasciculations hypotonia hyporeflexia weakness in root innervated pattern ```
32
Weakness in which muscles would occur due to compression of the following roots: C5? C6? C7?
C5: biceps, deltoid, spinati C6: brachioradialis C7: triceps, finger and wrist extensions
33
Sensory loss in which regions would occur due to compression of the following roots: C5? C6? C7?
C5: upper lateral arm C6: lower lateral arm, thumb, index finger C7: middle finger
34
Loss of which reflexes would occur due to compression of the following roots: C5? C6? C7?
C5: biceps C6: supinator C7: triceps
35
Discuss the management of cervical radiculopathy.
1. Analgesia: NSAIDs, paracetamol, prednisolone 2. Physiotherapy 3. Surgical root decompression
36
What types of surgery are available for a patient with cervical radiculopathy?
- anterior cervical discectomy with fusion - posterior nerve decompression - cervical arthroplasty
37
What is cervical myelopathy?
pressure on the spinal cord or the anterior spinal artery (supplies anterior 2/3 of cord) secondary to dorsomedial herniation of a disc, development of osteophyte bars or posterior osteophytes
38
What are the symptoms of cervical myelopathy?
``` radiculopathy: nerve root pain, shooting, electrical, paraesthenia, muscle spasms upper limb numbness clumsiness pronounced weakness gait disturbance falls urinary incontinence ```
39
What are the signs of cervical myelopathy?
insidious in onset UMN signs in legs first sensory loss common in arms but rare in legs muscle wasting may be present
40
How would you manage cervical myelopathy?
no evidence for any drugs multilevel surgical decompression and fusion often significant, irreversible neurological deficit prior to surgery goal to stabilise function, not improve
41
25 Year old male is complaining of pain and stiffness in his lower back and buttocks. What are your differentials?
ankylosing spondylitis, other axial spondylarthropathy, mechanical back pain, trauma, malignancy, infection, degenerative back pain
42
How does ankylosing spondylitis occur?
inflammation occurs at the site where ligaments or tendons attach to bone (enthesis) - leads to wearing of the bone (enthesopathy) as inflammation reduces, healing takes place and new bone develops, movement becomes restricted when bone replaces the elastic tissue of ligaments or tendons repetition of this process leads to further bone formation and vertebral fusion
43
What is the classification criteria for axial spondyloarthritis?
back pain > 3 months and age of onset < 45 years 1. Sacroiliitis on imaging* plus 1 or more SpA feature** OR 2. HLA-B27 plus 2 or more SpA features** *active inflammation on MRI highly suggestive of sacroiliitis associated with SpA or definite radiographic sacroiliitis according to mod. NY criteria
44
List some SpA features.
``` inflammatory back pain arthritis enthesitis uveitis dactylitis psoriasis Crohn's disease/UC good response to NSAIDs FHx HLA-B27 elevated CRP ```
45
How would you treat someone with ankylosing spondylitis?
``` pain relief DMARD - if peripheral or fail to improve on NSAIDs and PT PT OT lifestyle changes ```
46
What is Paget's disease of the bone?
a metabolic bone disorder characterised by increased bone turnover associated with increased numbers of osteoblasts and osteoclasts which results in remodelling, bone enlargement, deformity and increased risk of fractures
47
What sites are commonly affected in Paget's disease of the bone?
axial skeleton and lower extremities e.g. pelvis, femur, lumbar spine, skull, tibia, sacrum
48
Discuss the aetiology of Paget's disease of the bone.
cause unknown, several factors e.g. smoking, genetics, paramyxoviruses (measles, RSV, canine distemper virus) SQSTM1 (p62) mutation NF-KB activation
49
How do patients with Paget's disease typically present?
``` 70% asymptomatic raised AlkPhos XR changes bone/joint pain nerve compression symptoms ```
50
Describe Pagetic bone pain.
deep, boring pain that is usually worse at night, with rest, on weight-bearing but may be helped by movement
51
What are some of the complications which can arise with a diagnosis of Paget's disease of the bone?
neurological: nerve root compression, hearing loss, spinal stenosis orthopaedic: osteoarthritis, pathological fractures, enlargement/deformity oncological: osteosacroma heart failure secondary hyperparathyroidism
52
What might be seen in a Paget's X-ray?
localised bony enlargements or deformities, patchy cortical thickening with sclerosis
53
What is the most sensitive and specific test for Paget's?
bone biopsy - osteoclasts with increased numbers of nuclei and disorganised matric and lamellar bone formation
54
How would you manage a patient with Paget's disease of the bone?
- reduce metabolic activity - ensure normal Ca and Vit D levels - pharmacotherapy: analgesia, bisphosphonates, supplements - support: PT, OT, orthotics - surgical: corrective, joint replacement

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