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YEAR 1 MED > Back pain > Flashcards

Back pain Flashcards

1
Q

What should a history regarding back pain include specifically?

A
  • Age: older patients more likely to have disc disease and malignancy more common
  • Timescale: trauma? how long?
  • Leg pain: bilateral or unilateral
  • Neurology: numbness/weakness/tingling? change in bowel/bladder habits?
  • Screening: weight loss, systemic symptoms?
  • Any previous surgical intervention/injection or falls
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2
Q

What does a stooped posture with flexion of the knee suggest?

A
  • Sciatica
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3
Q

What does a frail elderly woman with stooped posture likely have?

A
  • Osteoporotic fractures in vertebra (vertebral wedge fractures)
  • (excessive kyphosis)
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4
Q

What are the main symptoms of mechanical back pain and clinical findings on examination?

A
  • Worse on movement
  • Mainly back pain (can radiate down leg but not true radiculopathy)
  • Straight leg raise: negative
  • Peripheral nerve examination: negative
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5
Q

What is the treatment for mechanical back pain?

A
  • Conservative: analgesia (NSAIDs), physio (avoid bed rest)
  • note: usually self-limiting, if persists then screen
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6
Q

What is a prolapsed intervertebral disc and where does it usually occur in the back?

A
  • a disc prolapse occurs when part of the nucleus pulposus herniates through the annulus fibrosus and presses on a spinal nerve root
  • note: usually occurs at L4-L5 or L5-S1 level
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7
Q

What are the symptoms of a prolapsed intervertebral disc (most likely causing sciatica)?

A
  • sciatica (pain radiating down leg)
  • may be numbness/tingling/weakness of the foot
  • often uncomfortable to sit
  • passive straight leg raise will: +ve
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8
Q

What are the symptoms of cauda equina syndrome (urgent MRI required)?

A
  • altered bladder/anal function (urinary retention or incontinence)
  • perineal pain/paraesthesia (saddle anaesthesia)
  • bilateral leg pain/paraesthesia/weakness
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9
Q

Why does cauda equina syndrome affect bladder/anal function, and cause perineal paraesthesia?

A
  • due to compression of the cauda equine which supplies motor function to the bowel and bladder sphincters, and sensation to the perineum
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10
Q

What is the main investigation for diagnosis of prolapsed intervertebral disc?

A
  • MRI
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11
Q

Cauda equina MRI image…

A
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12
Q

What is the management for a prolapsed intervertebral disc?

A
  • Conservative: physio, analgesia (NSAIDs)
  • (note: usually self-limiting)
  • Surgical: lumbar nerve root injection (can provide diagnosis and treatment for nerve root compression)
  • (note: surgical discectomy only for cauda equina or progressively worsening neurological deficit)
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13
Q

What is spondylolisthesis, where does it usually occur, and what is the aetiology?

A
  • Spondylolisthesis = one vertebral body slipping on another (usually occurs at the L5-S1 level)
  • Aetiology: commonly fast bowlers in cricket, gymnasts
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14
Q

Spondylolisthesis and the grades 1-4…

A
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15
Q

What are the clinical features of spondylolisthesis?

A
  • Most common cause of persistent back pain in children
  • Clinical examination: spinal tenderness, hyperextension painful, radiculopathy (sciatica) can occur
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16
Q

What investigations should be done for suspected spondylolisthesis?

A
  • X-ray: shows classic ‘collar on Scottie dog’ appearance (lateral x-ray view will show the degree and angle of slippage)
  • CT scan: clearly demonstrates the lesion
  • note: MRI if radiculopathy
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17
Q

‘Collar on Scottie dog’ appearance on x-ray in spondylolisthesis…

A
18
Q

What is the management for spondylolisthesis?

A
  • Conservative: physio, analgesia, and activity modification (usually self-limiting)
  • Surgical: fusion and bone graft (only if persistent pain, radiculopathy, and significant deformity)
19
Q

What is spinal stenosis?

A
  • Spinal stenosis = degenerative changes narrowing the spinal canal and causing compression of the nerve roots
20
Q

What are the risk factors for spinal stenosis?

A
  • Men over 50yrs
  • Heavy manual labourers
21
Q

What are the clinical symptoms of spinal stenosis?

A
  • pain when walking, reffered pain to the buttock, calves, and feet
  • pain worse on extension of spine, and is better with flexion of spine (flexion opens up spinal canal)
  • ‘Shoppping cart sign’: patients able to walk further when leaning on shopping trolley (spine is in flexion)
22
Q

What are the investigations that should be done for suspected spinal stenosis?

A
  • X-ray: will show degenerative changes
  • MRI: shows degree of stenosis and nerve root involvement
23
Q

What is the treatment for spinal stenosis?

A
  • Conservative: weight loss, physio, activity modification, analgesia (NSAIDs)
  • Surgical: surgical decompression if severe
24
Q

What is discitis / vertebral osteomyelitis?

A
  • Discitis = infection of the disc space
  • Vertebral osteomyelitis = infection of a vertebral body
25
Q

What are the risk factors for discitis / vertebral osteomyelitis?

A
  • IV drug users, immunocompromised patients, diabetes
  • Post disc surgery
  • Recent hx of sepsis or UTI
26
Q

What is Pott disease?

A
  • Tuberculosis (TB) of the spine
27
Q

What are the clinical features of discitis / vertebral osteomyelitis?

A
  • Systemically unwell (pyrexia), and severe unrelenting back pain
  • Clinical examination: swelling, tenderness, reduced movement, possible abnormal neurology
28
Q

What investigations should be done for suspected discitis / vertebral osteomyelitis?

A
  • Bloods: WCC, ESR, CRP all elevated
  • X-ray: narrowed disc space (discitis), bony destruction (osteomyelitis)
  • MRI: can detect a spinal epidural abscess (SEA)
  • Biopsy (CT guided): for culture
29
Q

Spinal epidural abscess (SEA)…

A
  • SEA = inflammation with pus inside the epidural space
30
Q

TB of the spine (Pott disease) MRI…

A
31
Q

What is the treatment for discitis / vertebral osteomyelitis?

A
  • Conservative: IV antibiotics for 6 weeks, follow-up MRI at 6 weeks
  • Surgical: any abscess should be drained, stabilisation if significant deformity
32
Q

What is the prognosis for discitis / vertebral osteomyelitis?

A
  • Can be life-threatening
  • Children: usually have good prognosis
33
Q

What is scoliosis?

A
  • Scoliosis = a lateral deviation and rotational abnormality of the spine
34
Q

What are the 4 types of scoliosis and their pathology?

A
  1. Congenital: abnormal development of the spine
  2. Adolescent idiopathic scoliosis
  3. Neuromuscular: abnormal muscle forces acting on the spine (eg. cerebral palsy)
  4. Secondary: curve develops secondary to another process (eg. leg-length discrepancy)
35
Q

What are the clinical features of scoliosis?

A
  • usually just cosmetic (pain-free)
  • curve more visible on forward flexion of spine
  • note: severe deformity reduces chest expansion and can be life-threatening
36
Q

What are the investigations for suspected scoliosis?

A
  • Standing X-ray: assess degree of the curve and monitor the progress of the curve
  • MRI: only to exclude other differentials
37
Q

What is the treatment for scoliosis?

A
  • Conservative: bracing if mild
  • Surgical: surgical stabilisation, fusion, correction if severe
38
Q

Scoliosis x-ray…

A
  • X-ray shows thoracolumbar curve
39
Q

Describe pharmacological interventions the GP should consider to manage a patient with chronic back pain.

A
  • Use of NSAIDs
  • Combine NSAIDs with proton-pump inhibitor (PPI) such as omeprazole
  • If NSAID not sufficient for pain then consider an opiod (dihydrocodeine)
  • Anti-depressant such as amitriptyline
40
Q

In chronic low back pain, the patient may progress through three phases, give examples of the typical features that may be seen in each phase

A
  • Phase 1 (up to 2 months): belief that pain is controllable, anxiety
  • Phase 2 (2 to 6 months): varying between increased and decreased activity, depression may occur
  • Phase 3 (6 to 24 months): reduced activity, side effects of pain medication may occur, belief that pain is uncontrollable, depression is common

YEAR 1 MED (49 decks)

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