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Rheumatology > Acute back pain/osteoporosis > Flashcards

Acute back pain/osteoporosis Flashcards

1
Q

List five red flags for lower back pain

A 
duration >6 weeks
weight loss
incontinence
bowel function
saddle anaesthesia 
pain worsened by coughing, sitting, or valsalva maneouvre, any neurological defect, age <18y >50y, cancer hx 
fever
nocturnal pain
fever, night sweats
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2
Q

Yellow flags for back pain?

A

social withdrawal, emotional problems, lack of support/overprotective family, belief that pain and activity are harmful

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3
Q

Four differentials for lower back pain?

A

Non-specific: muscle spasm, muscle sprain/strain, ligamentous injury

Vertebral compression fracture

Metastatic cancer

Cauda equina syndrome

Infections

Sciatica

Ankylosing spondylitis

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4
Q

Name five risk factors for osteoporosis

A
  1. early menopause
  2. smoking hx
  3. alcohol hx
  4. steroid use
  5. parent with hip fracture
  6. obesity
  7. female
  8. LOW BMI
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5
Q

How is osteoporosis formally diagnosed?

A

DXA scanning, T score <-2.5

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6
Q

What is the management of osteoporosis?

A
  1. Resistance training
  2. Lifestyle modification- smoking cessation, reducing alcohol
  3. Oral calcium
  4. Oral vitamin D
  5. Biphosphonate therapy
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7
Q

Acronym for surgical history (routine questions)

A 
AMPLE
allergies
medications
PMH
last eaten or drank
events leading to presentation
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8
Q

What are the components of a myeloma screen?

A

LDH, calcium/bone profile, ESR, urine bence jones protein, immunoglobulins and protein electrophoresis

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9
Q

What is the MOA of biphosphonates?

A

antiresorptive- bind to bone surface, once absorbed by osteoclasts, they activate apoptosis and result in cellular death of osteoclasts. Reduced bone loss but do not add new bone

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10
Q

Name a biphosphonate typical prescribed

A

alendronic acid

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11
Q

How would you advise a patient to administer their biphosphonate?

A
  • once per week
  • take first thing in the morning before food and other meds.
  • Drink plenty of water and sit upright for 30 mins and don’t eat or drink anything in this time. -Wait at least 4 hours before taking calcium/vit D supplement
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12
Q

Name three side effects of biphosphonates

A

nausea, osteonecrosis of jaw, oesophageal ulceration, heartburn/indigestion, headache, tiredness

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13
Q

Why should you not take calcium with alendronic acid?

A

calcium inactivates it

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14
Q

What would be an alternative biphosphonate to alendronic acid?

A

zolendronic acid, give as IV infusion once yearly!!

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15
Q

Which conditions are associated with osteoporosis?

A

T1D
osteogenesis imperfects
hyperthyroidism/hyperparathyroidism, chronic malnutrition, malabsorption e.g. crohn’s disease, chronic liver disease

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16
Q

What are the causes of fragility fractures?

A

osteoporosis and osteopenia

17
Q

Name three of the most common bone fractures relating to osteoporosis

A
  1. Femoral neck fracture
  2. Vertebral fracture
  3. Distal radius fracture
18
Q

Three differentials for back pain

A 
Mechanical 
  Strain/idiopathic 
  Trauma 
  Pregnancy  
  Disc prolapse 
  Spondylolisthesis (forward shift of one vertebra)

Degenerative: spondylosis, vertebral collapse, stenosis

Inflammatory: Ank spond, Paget’s

Neoplasm: Mets, myeloma

Infection: TB, abscess

19
Q

Three conservative options for back pain?

A

Physical activity
Advice on stooping, handling
Physio
Pyschosocial

20
Q

Two examples of neurosurgical emergencies associated with back pain

A

Acute cord compression

Acute cauda equina compression

21
Q

Two signs/symptoms of acute cord compression?

A

 Bilateral pain: back and radicular
 LMN signs at compression level
 UMN signs and sensory level below compression
 Sphincter disturbance

22
Q

Two signs/symptoms of cauda equina?

A

 Alternating or bilateral radicular pain in the legs
 Saddle anaesthesia
 Loss of anal tone
 Bladder ± bowel incontinence

23
Q

Two causes of acute cord compression and cauda equina syndrome

A

prolapse
tumours
abscess

24
Q

Define osteoporosis

A

a skeletal condition characterized by decreased density (mass/volume) of normally mineralized bone. This leads to decreased mechanical strength, thus making the skeleton more likely to fracture.

25
Q

Four risk factors for osteoporosis?

A 
SHATTERED
  Steroids 
  Hyperthyroidism, HPT, HIV 
  Alcohol and Cigarettes 
  Thin (BMI <22) 
  Testosterone Low  
  Early Menopause 
  Renal / liver failure 
  Erosive / inflam bone disease (e.g. RA, myeloma) 
  Dietary Ca low / malabsorption
26
Q

Which is the gold standard test in osteoporosis?

A

DEXA scan

27
Q

Two indications to perform DEXA scan?

A

 Low-trauma #
 Women ≥65yrs c¯ one or more risk factors
 Before giving long-term steroids (>3mo)
 Parathyroid disorders, myeloma, HIV

28
Q

DEXA result T=1. What does this imply?

A

bone density normal

29
Q

DEXA result T= -2. What does this imply?

A

osteopenia T -1 - -2.5

30
Q

DEXA result T= -3. What does this imply?

A

osteoporosis

31
Q

What is a FRAX score?

A

estimates the probability of a fracture within the next 10 years

32
Q

Two conservative options for managing osteoporosis?

A

stop smoking
drink less alcohol
Ca and Vit D rich diet
visual assessment- prevention of falling (+mobility aids?)

33
Q

What is the first line treatment for osteoporosis?

A

Biphosphonate- alendronate

34
Q

MOA of biphosphonates?

A

inhibit osteoclastic bone resorption

35
Q

Two SE of biphosphonates?

A

 GI upset
 Oesophageal ulceration / erosion- Take plenty of water on an empty stomach
and refrain from lying and don’t eat for 30min.
 Diffuse musculoskeletal pain
 Osteonecrosis of the jaw

36
Q

Name two biphophonates

A

alendroate/alendronic acid and zoledronic acid

37
Q

Name one other drug indicated in osteoporosis and provide its MOA

A

Teriparetide: PTH analogue → new bone formation

Denosumab: anti-RANKL → ↓ osteoclast activation

38
Q

List three lifestyle factor changes that promote bone health?

A

weight bearing exercise
smoking cessation
excessive alcohol cessation

39
Q

Which co-existing diagnosis often exists alongside osteoporosis? Name a blood test that would confirm this diagnosis

A

Osteomalacia

25-hydroxyvitamin D level

Rheumatology (19 decks)

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