Back Pain Flashcards
What are the functions of the spine (3)?
- Locomotor: capable of being both rigid & mobile
- Bony armour: protects the spinal cord
- Neurological: spinal cord transmission of signals between brain & periphery
How many vertebrae does the spinal column consist of?
24 bones
- 7 cervical
- 12 thoracic
- 5 lumbar
What is the function of the intervertebral discs of the spinal column (2)?
- Shock absorbers
- Allow segmentation & multi-directional movement
What are the facet joints of the spinal column?
- Small synovial joints at posterior spinal column linking each vertebra
What is the function of the muscles of the spinal column?
- Move the spine
Where does the spinal cord end?
L2
What is found after the spinal cord?
Cauda equina
Cauda equina: nerve bundle
What are the movements of the spinal cord (4)?
- Flexion (forward bend) vs extension (backward bend)
- Lateral flexion (side bend)
- Rotation (twist)
Outline the epidemiology of back pain?
Common
Effect
When does it get better
- 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
- Chronic back pain (>12 weeks duration) also common – sedentary lifestyle
- Need to distinguish mechanical back from serious pathology
What are the causes of back pain differentiated into?
- Mechanical back
- Serious pathology
What are the signs and symptoms of mechanical back pain?
When it comes to movement and rest
- Reproduced or worse with movement
- Better or not present at rest
What are the common causes of mechanical back pain (4)?
- Muscular tension (e.g. chronic poor posture, weak muscles)
- Acute muscle sprain / spasm
- Degenerative disc disease
- Osteoarthritis of facet joints
What symptom may is common with mechanical back pain?
Mechanical back pain caused by disc herniation
- Sciatica
Sciatica: pain radiating down one leg
What determines the location of pain caused by sciatica?
- Level of the herniated disc
What are the serious pathology causes of back pain (5)?
- Tumour
- Infection
- Inflammatory spondyloarthropathy
- Fracture (traumatic or atraumatic)
- Large disc prolapse causing neurological compromise
Referred pain (pancreas, kidneys, aortic aneurysm)
What types of tumour can cause back pain (2)?
- Metastatic cancer
- Myeloma
What serious infections can cause back pain (6)?
- Discitis
- Vertebral osteomyelitis
- Paraspinal abcess
- Microbiology:
- Staphylococcus
- Streptococcus
- Tuberculosis (TB)
What inflammatory spondyloarthropathy can cause back pain (3)?
- Ankylosing spondylitis
- Psoriatic arthritis
- Inflammatory bowel disease (IBD) - associated
What are the “red flag” symptoms of back pain that may indicate serious pathology (10)?
- 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
What are the symptoms / signs of cauda equina syndrome (5)?
- Cauda equina syndrome is a neurosurgical emergency
- Untreated = permanent lower limb paralysis and incontinence
- Saddle anaesthesia
- Bladder / bowel incontinence
- Loss of anal tone on PR
- Radicular leg pain
- Ankle jerks may be absent
What investigation is required in suspected cauda equina syndrom?
- Cauda equina syndrome is a neurosurgical emergency
- Untreated = permanent lower limb paralysis and incontinence
- Urgent MRI L spine
What are the causes cauda equina syndrome (5)?
- Cauda equina syndrome is a neurosurgical emergency
- Untreated = permanent lower limb paralysis and incontinence
- Large disc herniation
- Bony mets
- Myeloma
- TB
- Paraspinal abcess
What is the treatment of cauda equina syndrome?
- Cauda equina syndrome is a neurosurgical emergency
- Untreated = permanent lower limb paralysis and incontinence
- According to cause: may require urgent surgery
What is the treatment for low back pain without red flags (4)?
- Time
- Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
- AVOID bed rest: keep moving
-
Physiotherapy
- Soft tissue work
- Corrective exercises esp. core
What investigations (blood test) are recommended for back pain (6)?
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Full blood count (FBC)
- Alkaline phosphatase (ALP)
- Calcium
- PSA (prostate specific antigen)
When is erythrocyte sedimentation rate (ESR) abnormal in back pain?
Increased in:
* Myeloma
* Chronic inflammation
* TB
When is C-reactive protein (CRP) abnormal in back pain?
Increased in:
* Infection
* Inflammation
When is alkaline phosphatase (ALP) abnormal in back pain?
Increase in:
* Bony metastases (mets)
When is calcium abnormal in back pain?
May be increased in:
* Myeloma
* Bony metastases (mets)
When is full blood count (FBC) abnormal in back pain?
- Anaemia in:
- Myeloma
- Chronic disease
- Increase in:
- WCC in infection
When is PSA (prostate specific antigen) abnormal in back pain?
Increased in:
* Prostate cancer with bony mets
What investigations (imaging) are recommended for back pain (3)?
-
Radiographs (X-rays):
- Poor sensitivity, radiation
- Cheap, widely available
-
Computed tomography (CT) scans:
- Good for bony pathology, larger radiation dose
-
Magnetic resonance imaging (MRI):
- Best visualization of soft tissue structures like tendons and ligaments
- Best for spinal imaging: can see spinal cord and exiting nerve roots
- Expensive and time-consuming
What is the diagnosis:
* 70 year old woman
* Acute onset thoracic spine pain with radiation through to the chest wall
* Focally tender over thoracic spine
-
Osteoporotic vertebral collapse
- “Wedge fracture”
What is the diagnosis:
* 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
* Night sweats
-
L4/5 endplate destruction
- Soft tissue mass encroaching spinal canal
What is the diagnosis:
* A 45-year-old man complains of acute back pain and sciatica extending down the R leg into the foot associated with paresthesia
* No incontinence of bladder/bowel
* Examination: no weakness, sensation intact
* He has been off work for two weeks and wants to know when he can get back to work
Herniated discs
How is a herniated disc managed (3)?
-
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
What is the diagnosis:
* 25 year old woman
* Presents with 1 year history of lumbar and buttock pain, with morning stiffness lasting 2 hours
* Ibuprofen helps
* Examination: reduced range of L spine movements
- Inflammatory Spondyloarthritis (SpA)
- Ankylosing spondylitis (AS)
- Psoriatic arthritis
- Inflammatory bowel disease (IBD)
Inflammatory (SpA): Group of immune-mediated inflammatory diseases
What are the extra-articular manifestations of ankylosing spondylitis (AS)?
4A
- Anterior uveitis (iritis) – ocular inflammation
- Apical lung fibrosis
- Aortitis / aortic regurgitation
- Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
What is the strongest genetic risk factor for ankylosing spondylitis?
HLA-B27
+ve in 90% of AS patients versus
Which cytokines play important roles in the pathogenesis of ankylosing spondylitis (AS)?
- Tumour necrosis factor alpha (TNF-alpha)
- interleukin-17 (IL-17)
- interleukin-23 (IL-23)
How is ankylosing spondylitis managed?
- Physiotherapy and a life-long regular exercise programme
- Pharmacological
What is the 1st line of pharmacological treatment for ankylosing spondylitis (AS)?
- 1st line: non-steroidal anti-inflammatory drugs (NSAIDs)
- e.g. ibuprofen, naproxen, diclofenac
- Mechanism: NSAIDs inhibit cyclooxygenase 1 and 2 (COX1 and 2)
- Risks: peptic ulcer, renal, asthma exacerbation, ↑ atherothrombosis risk
- Selective COX2 inhibitors (e.g. celecoxib) reduce GI ulcer risk
What is the 2nd line of pharmacological treatment for ankylosing spondylitis (AS)?
- 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)
