Back pain Flashcards by Elizabeth Akeju

What are the functions of the spine?

Locomotor: capable of being both rigid and mobile
Bony armour: protects the spinal cord
Neurological: spinal cord transmission of signals between brain and periphery

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Where does the spinal cord end?

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What are the movements of the spine?

Flexion
Extension
Lateral flexion (side bend)
Rotation

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What defines chronic back pain?

Longer than 12 weeks duration
Can be associated with a sedentary lifestyle

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What are the features of back pain?

Very common: >50% of people will experience an episode
Acute back pain usually self-limiting
Most better in a few days, 96% are better in six weeks

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What are some features of mechanical back pain?

Reproduced or worse with movement
Better or not present at rest

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What are some common causes of mechanical back pain?

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

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Mechanical back pain may be accompanied by what?

Sciatica (pain radiating down one leg)

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What typically causes sciatica?

Sciatica typically due to a disc herniation (‘slipped disc’) contacting the exiting lumbar nerve root
Location of the pain determined by the level of the herniated disc

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What are some serious causes of back pain?

Tumour - Metastatic cancer or Myeloma
Infection
- Discitis
- Vertebral osteomyelitis
- Paraspinal abcess
- Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)
Inflammatory spondyloarthropathy
- Ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease (IBD)-associated
Fracture (traumatic or atraumatic)
Large disc prolapse causing neurological compromise
Can be referred pain - pancreas, kidneys, aortic aneurysm

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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

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Why is cauda equina syndrome a neurosurgical emergency?

Untreated - can cause permanent lower limb paralysis and incontinence

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What are the signs/symptoms of cauda equina syndrome?

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

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What investigation is used for suspected cauda equina syndrome?

Urgent MRI of lumbar spine

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What are the causes of cauda equina syndrome?

Large disc herniation
Bony metastases
Myeloma
Tuberculosis
Paraspinal abscess

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How is cauda equina syndrome treated?

Surgery may be required
Depends on cause

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What is covered in back pain history taking?

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 (muscle pain due to lack of oxygen triggered by activity)

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How is the spine examined?

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

If there any no red flags, is investigation required?

No usually not required

What are the NICE guidelines for non-specific back pain in primary care?

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

How is lower back pain without red flags treated?

Time
Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
AVOID bed rest: keep moving
Physiotherapy
Soft tissue work
Corrective exercises esp. core

What tests are used to investigate back pain?

Erythrocyte sedimentation rate (ESR):
↑ in myeloma, chronic inflammation, TB
C-reactive protein (CRP):
↑ in infection or inflammation
Full blood count (FBC):
anaemia in myeloma, chronic disease
↑ WCC in infection
Alkaline phosphatase (ALP):
↑ with bony metastases (mets)
Calcium:
may be ↑ in myeloma, bony metastases (mets)
PSA (prostate specific antigen):
prostate Ca with bony mets

What are the pros and cons of using X-ray imaging for back pain?

Pros:
-cheap, widely available

Cons:
-poor sensitivity, use of radiation

What are the pros and cons of using CT imaging for back pain?

Pro:
-good for bony pathology

Con:
-larger radiation dose

What are the pros and cons of using MRI imaging for back pain?

Pros: -Best visualization of soft tissue structures like tendons and ligaments -Best for spinal imaging: can see spinal cord and exiting nerve roots Cons: -Expensive and time-consuming

What is the diagnosis of this x-ray?

Osteoporotic vertebral collapse ‘Wedge fracture’

What does this show?

Wedge fracture

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 and Night sweats What is the likely diagnosis considering the radiography and history?

Infection - likely TB Age is not suggestive of cancer - unlikely

What is the natural history of herniated discs?

Most prevalent in individuals aged 30-50 Good outlook Normally spontaneous improvement, although typically slower than for lower back pain alone

How are herniated discs treated?

1. Conservative as for LBP without sciatica -Analgesia especially NSAIDs -Physiotherapy to improve core strength and treat associated muscle spasm 2. Nerve root injection (local anaesthetic and glucocorticoid) 3. Surgery if neurological compromise or symptoms persist however trials of surgery vs conservative Rx show no long term advantage for surgery

What does this image show?

Spontaneous resolution of prolapsed lumbar disc (studies reveal that the herniated portion of the disc tends to regress with time)

What is inflammatory spondyloarthritis (SpA)?

Group of immune-mediated inflammatory diseases Includes ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD) Primarily involves inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis) Peripheral joints, esp. tendon insertions (entheses), can also be affected

What are the extra-articular manifestations of inflammatory spondyloarthritis?

Anterior uveitis (iritis) – ocular inflammation Apical lung fibrosis Aortitis/aortic regurgitation Amyloidosis – due to serum amyloid A (SAA) depositing chronically in organs 4 As

What is this called and which condition is it a sign of?

Anterior uveitis Implicated in inflammatory SpA

What is the name of this abnormality and what causes it?

Dactylitis Due to enthesitis Implicated in inflammatory SpA

What is a hallmark feature of ankylosing spondylitis?

Loss of spinal movements

What is the pathophysiology of ankylosing spondylitis?

Characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)

What role does genetics play in ankylosing spondylitis?

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 However, HLA-B27 +ve alone does not mean you’ll develop ankylosing spondylitis

What do these two images show?

Sacro-ilitis -> radiograph (top), MRI (bottom)

What is the natural progression of untreated ankylosing spondylitis (AS)?

Spinal enthesitis -> bridging syndesmophytes (new bone growth between adjacent vertebra) -> spinal fusion

What role can MRI play in diagnosing AS?

MRI can detect spinal inflammation before X-ray changes develop “Shiny corners” sign

How is AS managed?

1) Physiotherapy and a life-long regular exercise programme 2) Pharmacological 1st line: non-steroidal anti-inflammatory drugs (NSAIDs) e.g. ibuprofen, naproxen, diclofenac Selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk 2nd line: ‘Biological’ therapies 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)

What are the risks of taking NSAIDs?

Inhibit cyclooxygenase 1 and 2 (COX1 and 2) Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk