Back pain Flashcards
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
Where does the spinal cord end?
L2
What are the movements of the spine?
Flexion
Extension
Lateral flexion (side bend)
Rotation
What defines chronic back pain?
Longer than 12 weeks duration
Can be associated with a sedentary lifestyle
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
What are some features of mechanical back pain?
Reproduced or worse with movement
Better or not present at rest
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
Mechanical back pain may be accompanied by what?
Sciatica (pain radiating down one leg)
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
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
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
Why is cauda equina syndrome a neurosurgical emergency?
Untreated - can cause permanent lower limb paralysis and incontinence
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
What investigation is used for suspected cauda equina syndrome?
Urgent MRI of lumbar spine
What are the causes of cauda equina syndrome?
Large disc herniation
Bony metastases
Myeloma
Tuberculosis
Paraspinal abscess
How is cauda equina syndrome treated?
Surgery may be required
Depends on cause
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)
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?
- Conservative as for LBP without sciatica
-Analgesia especially NSAIDs
-Physiotherapy to improve core strength and treat associated muscle spasm - Nerve root injection (local anaesthetic and glucocorticoid)
- 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
