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MSK > Back pain > Flashcards

Back pain Flashcards

1
Q

What are the three functions of the spine?

A

Locomotor (rigid for support and mobile),
Bony armour, protects spinal cord
Neurological (spinal cord transmission of signals)

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2
Q

Normal kyphosis and vertebral section that exhibits it

A

Thoracic spine
outward bend -> dorsal facing

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3
Q

Normal lordosis and vertebral section that exhibits it

A

Cervical spine and Lumbar spine
inward bend -> ventral facing

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4
Q

Function of intervertebral discs

A

Shock absorbers
allow segmentation and multidirectional movement

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5
Q

Function of facet joints?

A

Link each vertebra on the posterior side

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6
Q

At what point does the spinal cord end?

A

L2

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7
Q

What movement of the spine is touching your toes?

A

Flexion

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8
Q

What movement of the spine is looking at the ceiling?

A

Extension

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9
Q

What movement of the spine is a sideways bend?

A

Lateral Flexion

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10
Q

What are the possible spinal movements

A

Flexion
Extension
Lateral flexion
Rotation

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11
Q

How long does back pain have to last to be chronic?

A

> 12 weeks

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12
Q

What are common causes of mechanical back pain?

A

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

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13
Q

How does movement affect mechanical back pain?

A

Worsens

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14
Q

How does rest affect mechanical back pain?

A

Better or not present

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15
Q

What is sciatica?

A

Pain radiating down one leg

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16
Q

What is sciatica typically caused by?

A

Disc herniation - contact with lumbar nerve root

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17
Q

Describe the structure of an intervertebral disc

A

Jelly-like centre called nucleus pulposus
Fibrous outer annulus fibrosus

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18
Q

Mechanism behind disc hernation

A

Tear in annulus fibrosus, jelly like nucleus pulposus leaks out, contact with nerve root which causes irritation and pain

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19
Q

What are 5 causes of serious back pain?
I LIFT

A

Infection,
Large disc prolapse,
Inflammatory Spondyloarthropathy,
Fracture, (traumatic/atraumatic)
Tumour

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20
Q

What are some examples of infection causing serious back pain?

A

Discitis - infection of intervertebral discs
Vertebral Osteomyelitis - infection of bone vertebrae
Paraspinal Abscess - collection of pus which can compress nerves

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21
Q

Infectious Microbes causing serious back pain

A

Staph
Strep
TB

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22
Q

Types of tumour causing serious back pain

A

Myeloma, plasma malignancy
Metastatic cancer, spread from primary location to spine

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23
Q

What is inflammatory spondyloarthropathy?

A

Inflammatory arthritis affecting the spine
immune mediated

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24
Q

What are some causes of inflammatory spondyloarthropathy?

A

Ankylosing Spondylitis, Psoriatic Arthritis, IBD

25
Q

What can cause referred pain to the back

A

pancreatic issues
kidney issues
aortic aneurysm

26
Q

What are some red flags of serious back pain?

A

Weight loss/fever/night sweats, (infection)
age<20 or >55,
immunosuppressed,
thoracic pain, (unlikely in mechanical pain)
constant/supine/worsening pain,
bladder/bowel dysfunction (sphincter dysfunction)
leg weakness/sensory loss

27
Q

What is cauda equina syndrome

A

Compression of the nerve roots of the cauda equina
If untreated can cause permanent lower limb paralysis and incontinence

28
Q

Red flags of cauda equina?

A

Saddle anaesthesia, (area that would contact saddle)
bowel incontinence,
loss of anal tone,
Radicular leg pain

29
Q

Investigations for cauda equina

A

urgent lumbar MRI

30
Q

Causes of cauda equina

A

Large disc herniation
Bony mets
herniation
TB
paraspinal abscess

31
Q

Treatment of cauda equina

A

Varies according to cause
can be surgical
radiotherapy for mets

32
Q

Extra things to ask for a back pain history
(in addition to SOCRATES)

A

Prolonged morning stiffness - may indicate ankylosing spondylitis
effect of movement/inactivity
buttock pain - may be pain referral/AnkyS
leg weakness
sensory loss
LL claudication - inadequate arterial blood supply (spinal stenosis)

33
Q

What are the steps of examining a spine?

A

Look, Feel, Move, Straight Leg Raise, Lower limb neurological exam

34
Q

What is the straight leg raise

A

Test for sciatica
patient lying, lift leg straight, pins + needles = +ve sign

35
Q

How do you treat back pain without red flags?

A

Time,
Analgesia (NSAIDs),
Movement, avoid bed rest
Physiotherapy

36
Q

What blood tests do you do for back pain?

A

ESR - infection, myeloma
CRP - infection
FBC - anaemia in myeloma
PSA - prostate cancer can cause bony mets
Calcium - myeloma, mets
Alkaline phosphatase ALP - mets

37
Q

What is an advantage and disadvantage of XRays?

A

Cheap & available
poor sensitivity, involve radiation

38
Q

What is an advantage and disadvantage of CTs?

A

Better bony pathology visualisation
larger radiation dose

39
Q

What is an advantage and disadvantage of MRIs?

A

Best visualisation of soft tissue e.g. ligaments/tendons
Best for spinal imaging - see the cord and roots
Expensive and time consuming

40
Q

What is a wedge fracture indicative of

A

Osteoporotic vertebral collapse
underlying osteoporosis causes the vertebrae to wear down

41
Q

What is the conservative treatment for herniated discs?

A

Analgesia, Physiotherapy

42
Q

What are further treatments for herniated discs?

A

Nerve root injection (LA and glucocorticoid), - after MRI to locate site of injury
Surgery, for persistent symptoms

43
Q

Sites of inflammation in Inflammatory Spondyloarthritis

A

Spine - spondylitis
sacro-iliac jts - sacro-iliitis
Peripheral joints esp tendon insertions -entheses

44
Q

Non MSK manifestations of inflamm spondyloarthropy (xtra articular)

A

Anterior uveitis - ocular inflamm
Apical lung fibrosis
Aortitis/Aortic regurg
Amyloidosis - serum amyloid deposits in organs
Dactylitis - swollen fingers

45
Q

How does ankylosing spondylitis present?

A

Loss of spinal movements

46
Q

What is AnkyS characterised by

A

Enthesitis - inflammation of soft tissue insertions

47
Q

What is the strongest genetic risk factor for ankylosing spondylitis?

A

HLA-B27 in MC1
polygenic presentation
clinical diagnostic marker

48
Q

What cytokines are involved in the pathogenesis of ankylosing spondylitis?

A

TNF-Alpha, IL-17, IL-23

49
Q

What other processing pathway may be aberrant in AS?

A

Aminopeptidases in endoplasmic reticulum

50
Q

How can you see ankylosing spondylitis on an XRay?

A

Increased whiteness in sacroiliac joints, suggests bone inflamm

51
Q

Progression of untreated AnkyS

A

Spinal enthesitis
-> Calcification of etheses form bony syndesmophytes (bony growth btw vertebrae)
-> Spinal fusion

52
Q

How can you see ankylosing spondylitis on an MRI?

A

Detects spinal inflamm b4 Xray
Shiny corners of L4, L5 and S1

53
Q

What are the two types of management of ankylosing spondylitis?

A

Physiotherapy and Pharmacological

54
Q

What is the first line of pharmacological treatment of ankylosing spondylitis?

A

NSAIDs

55
Q

What is the mechanism of action of NSAIDs?

A

Inhibit COX enzyme that makes prostaglandins (inflammation)

56
Q

What are the risks of NSAIDs?

A

Peptic ulcer, renal impairments, asthma exacerbation, atherothrombosis, CVD risk

57
Q

Why do NSAIDs cause asthma exacerbation?

A

Arachidonic acid can no longer go down prostaglandin pathway, more into leukotriene pathway - bronchoconstriction

58
Q

How can you reduce the risk of GI ulcers?

A

COX2 Inhibitors

59
Q

What is the second line treatment for ankylosing spondylitis?

A

Biological therapies - monoclonal antibodies such as Anti-TNFA-Alpha (infliximab), Anti-IL17
Target specific molecules

MSK (7 decks)

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