Back pain Flashcards by Sharon Adeniran

What are the three functions of the spine?

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

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Normal kyphosis and vertebral section that exhibits it

Thoracic spine
outward bend -> dorsal facing

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Normal lordosis and vertebral section that exhibits it

Cervical spine and Lumbar spine
inward bend -> ventral facing

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Function of intervertebral discs

Shock absorbers
allow segmentation and multidirectional movement

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Function of facet joints?

Link each vertebra on the posterior side

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At what point does the spinal cord end?

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What movement of the spine is touching your toes?

Flexion

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What movement of the spine is looking at the ceiling?

Extension

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What movement of the spine is a sideways bend?

Lateral Flexion

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What are the possible spinal movements

Flexion
Extension
Lateral flexion
Rotation

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

> 12 weeks

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What are common causes of mechanical back pain?

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

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How does movement affect mechanical back pain?

Worsens

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How does rest affect mechanical back pain?

Better or not present

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What is sciatica?

Pain radiating down one leg

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What is sciatica typically caused by?

Disc herniation - contact with lumbar nerve root

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Describe the structure of an intervertebral disc

Jelly-like centre called nucleus pulposus
Fibrous outer annulus fibrosus

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Mechanism behind disc hernation

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

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What are 5 causes of serious back pain?
I LIFT

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

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What are some examples of infection causing serious back pain?

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

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Infectious Microbes causing serious back pain

Staph
Strep
TB

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Types of tumour causing serious back pain

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

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What is inflammatory spondyloarthropathy?

Inflammatory arthritis affecting the spine
immune mediated

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What are some causes of inflammatory spondyloarthropathy?

Ankylosing Spondylitis, Psoriatic Arthritis, IBD

What can cause referred pain to the back

pancreatic issues kidney issues aortic aneurysm

What are some red flags of serious back pain?

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

What is cauda equina syndrome

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

Red flags of cauda equina?

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

Investigations for cauda equina

urgent lumbar MRI

Causes of cauda equina

Large disc herniation Bony mets herniation TB paraspinal abscess

Treatment of cauda equina

Varies according to cause can be surgical radiotherapy for mets

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

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)

What are the steps of examining a spine?

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

What is the straight leg raise

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

How do you treat back pain without red flags?

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

What blood tests do you do for back pain?

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

What is an advantage and disadvantage of XRays?

Cheap & available poor sensitivity, involve radiation

What is an advantage and disadvantage of CTs?

Better bony pathology visualisation larger radiation dose

What is an advantage and disadvantage of MRIs?

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

What is a wedge fracture indicative of

Osteoporotic vertebral collapse underlying osteoporosis causes the vertebrae to wear down

What is the conservative treatment for herniated discs?

Analgesia, Physiotherapy

What are further treatments for herniated discs?

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

Sites of inflammation in Inflammatory Spondyloarthritis

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

Non MSK manifestations of inflamm spondyloarthropy (xtra articular)

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

How does ankylosing spondylitis present?

Loss of spinal movements

What is AnkyS characterised by

Enthesitis - inflammation of soft tissue insertions

What is the strongest genetic risk factor for ankylosing spondylitis?

HLA-B27 in MC1 polygenic presentation clinical diagnostic marker

What cytokines are involved in the pathogenesis of ankylosing spondylitis?

TNF-Alpha, IL-17, IL-23

What other processing pathway may be aberrant in AS?

Aminopeptidases in endoplasmic reticulum

How can you see ankylosing spondylitis on an XRay?

Increased whiteness in sacroiliac joints, suggests bone inflamm

Progression of untreated AnkyS

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

How can you see ankylosing spondylitis on an MRI?

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

What are the two types of management of ankylosing spondylitis?

Physiotherapy and Pharmacological

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

NSAIDs

What is the mechanism of action of NSAIDs?

Inhibit COX enzyme that makes prostaglandins (inflammation)

What are the risks of NSAIDs?

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

Why do NSAIDs cause asthma exacerbation?

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

How can you reduce the risk of GI ulcers?

COX2 Inhibitors

What is the second line treatment for ankylosing spondylitis?

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