Back Pain Flashcards by Callum Reeson

What are the three clasifications of spinal functions

Locomotor, bony armour, neurological

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What are the locomotor functions of the spine?

Capable of being both rigid and mobile

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What are the bony armour functions of the spine?

Protection of the spinal cord

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What are the neurological functions of the spine?

Spinal cord transmission of signals between brain and periphery

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How many vertebrae make up the spine and of which type?

24 overall
7 cervical, 12 thoracic and 5 lumbar

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What is the function of intervertebral disks?

Shock absorbers, allow segmentation and multi-directional movement

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What are facets joints?

Small synovial joints at posterior spinal column linking each vertebrae

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What are the key neurological structures in the spine?

Spinal cord, nerve roots, cauda equine

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Where does the spinal cord end?

L2 vertebrae

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Where is a lumbar puncture performed and why?

Performed at L3/4 space to avoid spinal cord

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What are the three types of spinal movement?

Flexion/extension
Lateral flexion
Rotation

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After how many weeks is back pain classified as chronic?

12 weeks

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What are the four common causes of mechanical back pain?

Muscular tension
Acute muscle sprain/spasm
Degenerative disc disease
Osteoarthritis of facet joints

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What is the first thing to distinguish when assessing back pain?

Mechanical back pain from serious pathology

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What is mechanical back pain defining feature?

Worsens with movement, better or not present at rest

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What term describes the pain radiating down one leg that often accompanies back pain?

Sciatica

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What is the most probable cause of sciatica?

A disc herniation contacting the exiting lumbar nerve root

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What are the 5 more serious causes of back pain?

Tumour, infection, inflammatory spondyloarthropathy, fracture, large disc prolapse (cauda equina)

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What tumours are often found that cause back pain?

Metastatic cancer or myeloma

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What infection can cause serious back pain?

Discitis, vertebral osteomyelitis, paraspinal absess, microbiology (staph, strep, TB)

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What are the three most common types of inflammatory spondyloarthropathy that result in back pain?

ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease (IBD)-associated

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How does a large disc prolapse result in back pain?

Causes neurological compromise

What are the red flag symptoms of back pain?

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

How is a history regarding back pain taken?

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

Outline the process of examination of the spine

Look •Feel •Move •Straight leg raise (SLR) •Lower limb neurological exam •General exam (signs of malignancy, AAA)

Cauda equina syndrome if untreated can result in what?

Is a neurosurgical emergency, can result in permanent lower limb paralysis and incontinence

When is an investigation for back pain required?

In the absence of red flags, investigation not required

What is the line of treatment for low back pain without red flags?

Time, analgesia, avoiding bed rest, physiotherapy

what analgesics are prescribed to treat lower back pain without red flags?

NSAIDs- ibuprofen, paracetamol, codeine

What specific markers are looked at in a blood test for investigating back pain?

Erythrocyte sedimentation rate, CRP, Full blood count, alkaline phosphatase, calcium , PSA

What abnormalities associated with Lower back pain would result in an increased ESR?

Myeloma, chronic inflammation, TB

What abnormalities associated with lower back pain would result in an increased CRP?

Infection of inflammation

What abnormalities associated with lower back pain would result in an increased ALP?

Bony metastases

Which abnormalities associated with lower back pain would result in an increase in calcium levels?

May be increased in myeloma or with bony metyastases

What abnormalities associated with lower back pain would result in an increase in PSA in the blood?

Prostate cancer with bony mets

What is the strongest genetic risk factor for ankylosing spondylitis?

HLA-B27

What type of MHC molecule is HLA-B27?

MCH type 1

Which cytokine play an important role in the pathogenesis of ankylosing spondylitis?

How does sacro-illiitis seen on an MRI?

White spots either side of sacro-iliac joint

What is the line of management for ankylosing spondylitis?

1. Physiotherapy 2. Pharmacological - NSAIDs 3. Biologics - anti-TNFalpha (infliximab)

By what mechanism do NSAIDs treat ankylosing spondylitis?

Inhibit cylcooxygenase 1 and 2 so less prostaglandin formation

How do nerve roots exit the spinal cord?

Bilaterally

What is the cauda equina?

Nerve bundle

Does flexion or extension of the back describe forward bend?

Flexion

What are the common causes of mechanical back pain?

Muscular tension (poor posture, weak muscles) Acute muscle sprain/ spasm Degenerative disc disease Osteoarthritis of facet joints

Location of sciatica pain is determined by what?

Level of the herniated disc

What are the signs and symptoms associated with cauda equina syndrome?

Saddle anaesthesia Bladder or bowel incontinence Loss of anal tone on PR Bilateral sciatica

What investigations are made for suspected cauda equina?

Urgent MRI lumbar spine

What are the causes of cauda equina syndrome?

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

What is inflammatory spondyloarthritis SpA?

Group of immune-related inflammatory diseases - ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease

Primarily what does inflammatory spondyloarthritis cause?

Inflammation of the spin (spondylitis) and sacro-iliac joints (sacro-iliitis)

What are the four extra-articular manifestations of SpA? AAAA

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

Ankylosing spondylitis is characterised by what?

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

What is the natural progression of untreated AS?

Spinal enthesitis Bridging spyndesmophytes Spinal fusion