Back pain Flashcards
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)
Normal kyphosis and vertebral section that exhibits it
Thoracic spine
outward bend -> dorsal facing
Normal lordosis and vertebral section that exhibits it
Cervical spine and Lumbar spine
inward bend -> ventral facing
Function of intervertebral discs
Shock absorbers
allow segmentation and multidirectional movement
Function of facet joints?
Link each vertebra on the posterior side
At what point does the spinal cord end?
L2
What movement of the spine is touching your toes?
Flexion
What movement of the spine is looking at the ceiling?
Extension
What movement of the spine is a sideways bend?
Lateral Flexion
What are the possible spinal movements
Flexion
Extension
Lateral flexion
Rotation
How long does back pain have to last to be chronic?
> 12 weeks
What are common causes of mechanical back pain?
Muscular tension (poor posture, weak muscles),
Acute sprain/spasm,
Degenerative disc disease
Osteoarthritis of facet joints
How does movement affect mechanical back pain?
Worsens
How does rest affect mechanical back pain?
Better or not present
What is sciatica?
Pain radiating down one leg
What is sciatica typically caused by?
Disc herniation - contact with lumbar nerve root
Describe the structure of an intervertebral disc
Jelly-like centre called nucleus pulposus
Fibrous outer annulus fibrosus
Mechanism behind disc hernation
Tear in annulus fibrosus, jelly like nucleus pulposus leaks out, contact with nerve root which causes irritation and pain
What are 5 causes of serious back pain?
I LIFT
Infection,
Large disc prolapse,
Inflammatory Spondyloarthropathy,
Fracture, (traumatic/atraumatic)
Tumour
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
Infectious Microbes causing serious back pain
Staph
Strep
TB
Types of tumour causing serious back pain
Myeloma, plasma malignancy
Metastatic cancer, spread from primary location to spine
What is inflammatory spondyloarthropathy?
Inflammatory arthritis affecting the spine
immune mediated
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
