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BRS MUSCULOSKELETAL And RHEUM > Back Pain > Flashcards

Back Pain Flashcards

1
Q

What are the functions of the spine (3)?

A
  • Locomotor: capable of being both rigid & mobile
  • Bony armour: protects the spinal cord
  • Neurological: spinal cord transmission of signals between brain & periphery
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2
Q

How many vertebrae does the spinal column consist of?

24 bones

A
  • 7 cervical
  • 12 thoracic
  • 5 lumbar

24 total

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3
Q

What is the function of the intervertebral discs of the spinal column (2)?

A
  • Shock absorbers
  • Allow segmentation & multi-directional movement
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4
Q

What are the facet joints of the spinal column?

A
  • Small synovial joints at posterior spinal column linking each vertebra
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5
Q

What is the function of the muscles of the spinal column?

A
  • Move the spine
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6
Q

What is Lordosis

A

Normal curvature of the lower spine

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7
Q

What is kyphosis

A

The outward curve of the thoracic spine

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8
Q

Where does the spinal cord end?

A

L2

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9
Q

What is found after the spinal cord?

A

Cauda equina

Cauda equina: nerve bundle

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10
Q

At what level is a lumbar puncture performed?

A

L3/4 to avoid spinal chord damage

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11
Q

What are the two components of the intervertebral disc?

A

Nucleus pulposus
Annulus fibrosus

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12
Q

What are the movements of the spinal cord (4)?

A
  • Flexion (forward bend) vs extension (backward bend)
  • Lateral flexion (side bend)
  • Rotation (twist)
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13
Q

Outline the epidemiology of back pain?

Common
Effect
When does it get better

A
  • 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
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14
Q

What are the causes of back pain differentiated into?

A
  • Mechanical back
  • Non-specific
  • Nerve root back pain
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15
Q

What are the signs and symptoms of mechanical back pain?

When it comes to movement and rest

A
  • Reproduced or worse with movement
  • Better or not present at rest
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16
Q

What are the common causes of mechanical back pain (4)?

A
  • Muscular tension (e.g. chronic poor posture, weak muscles)
  • Acute muscle sprain / spasm
  • Degenerative disc disease
  • Osteoarthritis of facet joints
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17
Q

What symptom may is common with mechanical back pain?

Mechanical back pain caused by disc herniation

A
  • Sciatica

Sciatica: pain radiating down one leg

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18
Q

What causes sciatica?

A

Disc herneation (slipped disc) which then comes into contact with the exiting lumbar nerve root

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19
Q

What determines the location of pain caused by sciatica?

A
  • Level of the herniated disc
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20
Q

What are the serious pathological causes of back pain (5)?

A
  • Tumour
  • Infection
  • Inflammatory spondyloarthropathy
  • Fracture (traumatic or atraumatic)
  • Large disc prolapse causing neurological compromise

Referred pain (pancreas, kidneys, aortic aneurysm)

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21
Q

what infective condition can commonly cause back pain?

A

TB- insidious onset

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22
Q

What types of tumour can cause back pain (2)?

A
  • Metastatic cancer
  • Myeloma
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23
Q

What serious infections can cause back pain (6)?

A
  • Discitis
  • Vertebral osteomyelitis
  • Paraspinal abcess
  • Microbiology:
    • Staphylococcus
    • Streptococcus
    • Tuberculosis (TB)
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24
Q

What inflammatory spondyloarthropathy can cause back pain (3)?

A
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Inflammatory bowel disease (IBD) - associated
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25
Q

What are the “red flag” symptoms of back pain that may indicate serious pathology (10)?

A
  • 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
26
Q

What are the symptoms / signs of cauda equina syndrome (5)?

  • Cauda equina syndrome is a neurosurgical emergency
    • Untreated = permanent lower limb paralysis and incontinence
A
  • Saddle anaesthesia
  • Bladder / bowel incontinence
  • Loss of anal tone on PR
  • Radicular leg pain
  • Ankle jerks may be absent
27
Q

What investigation is required in suspected cauda equina syndrom?

  • Cauda equina syndrome is a neurosurgical emergency
    • Untreated = permanent lower limb paralysis and incontinence
A
  • Urgent MRI of lower spine
28
Q

What are the causes of cauda equina syndrome (5)?

A

When the nerves which run lower than L1 are compressed:
* Large disc herniation
* Bony mets
* Myeloma
* TB
* Paraspinal abcess

29
Q

If untreated what does CES lead to?

A
  • CES is a neurosurgical emergency
  • If untreated can cause permanent lower limb paralysis and incontinence
30
Q

What is the treatment of cauda equina syndrome?

A
  • According to cause: may require urgent surgery
31
Q

In which situation is imvestigations not usually required?

A

in the absence of red flags

32
Q

What is the treatment for low back pain without red flags (4)?

A
  • Time
  • Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
  • AVOID bed rest: keep moving
  • Physiotherapy
    • Soft tissue work
    • Corrective exercises esp. core
33
Q

What investigations (blood test) are recommended for back pain (6)?

A
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Full blood count (FBC)
  • Alkaline phosphatase (ALP)
  • Calcium
  • PSA (prostate specific antigen)
34
Q

When is erythrocyte sedimentation rate (ESR) abnormal in back pain?

A

Increased in:
* Myeloma
* Chronic inflammation
* TB

35
Q

When is C-reactive protein (CRP) abnormal in back pain?

A

Increased in:
* Infection
* Inflammation

36
Q

When is alkaline phosphatase (ALP) abnormal in back pain?

A

Increase in:
* Bony metastases (mets)

37
Q

When is calcium abnormal in back pain?

A

May be increased in:
* Myeloma
* Bony metastases (mets)

38
Q

When is full blood count (FBC) abnormal in back pain?

A
  • Anaemia in:
    • Myeloma
    • Chronic disease
  • Increase in:
    • WCC in infection
39
Q

When is PSA (prostate specific antigen) abnormal in back pain?

A

Increased in:
* Prostate cancer with bony mets

40
Q

What investigations (imaging) are recommended for back pain (3)?

A
  • 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
41
Q

What is the diagnosis and does she need investigation?:
* 70 year old woman
* Acute onset thoracic spine pain with radiation through to the chest wall
* Focally tender over thoracic spine

A
  • Thoracic = red flag so needs investigation
  • Osteoporotic vertebral collapse
    • “Wedge fracture”
42
Q

What is a wedge fracture?

A

A compression fracture of the spinal column in which the front side of the spine collapses, resulting in a wedge shape

43
Q

What is the diagnosis and does he need investigation?:
* 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

A

Needs investigation (weight loss, night sweats)
* L4/5 endplate destruction
* Soft tissue mass encroaching spinal canal
* T2: altered signal in sacral segments

44
Q

How is a herniated disc managed (3)?

A
  • 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
45
Q

What is the conservative treatment of a herneated disk?

A
  • Analgesia especially NSAIDs
  • Physiotherapy to improve core strength and treat associated muscle spasm
46
Q

What is the nerve root injection for a herneated disk?

A

local anaesthetic and glucocorticoid

47
Q

When would surgery be considered for a herniated disc?

A

If neurological compromise or symptoms persist

48
Q

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

A

Herniated discs

49
Q

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

A
  • Inflammatory Spondyloarthritis (SpA)
    • Ankylosing spondylitis (AS)
    • Psoriatic arthritis
    • Inflammatory bowel disease (IBD)

Inflammatory (SpA): Group of immune-mediated inflammatory diseases

50
Q

What is inflammatory spondyloarthritis?

A

Primary inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-illitis)

Peripheral joints, esp. tendon insertions (entheses), can also be affected

51
Q

What are the extra-articular manifestations of ankylosing spondylitis (AS)?

4A

A
  • Anterior uveitis (iritis) – ocular inflammation
  • Apical lung fibrosis
  • Aortitis / aortic regurgitation
  • Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
52
Q

What effect does ankylosing spondilitis have on the spine?

A

Loss of spinal moevements

53
Q

What is the pathophysiology of ankylosing spondylitis?

A

Charactarised by enthesitis (inflammation of the entheses- sites where tendons and ligaments join to bone)

54
Q

What is the strongest genetic risk factor for ankylosing spondylitis?

A

HLA-B27

+ve in 90% of AS patients versus

55
Q

Which 3 cytokines play important roles in the pathogenesis of ankylosing spondylitis (AS)?

A
  • Tumour necrosis factor alpha (TNF-alpha)
  • interleukin-17 (IL-17)
  • interleukin-23 (IL-23)
56
Q

What is the natural progression of AS?

A

Spinal enthesitis
->
Bridging syndesmophytes
(new bone growth between adjacent vertebra)
->
Spinal fusion

57
Q

What is seen on an MRI of the spine in a patient with AS?

A

Shiny corners sign

58
Q

How is ankylosing spondylitis managed?

A
  • Physiotherapy and a life-long regular exercise programme
  • Pharmacological
59
Q

What is the 1st line of pharmacological treatment for ankylosing spondylitis (AS)?

A
  • 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
60
Q

What is the 2nd line of pharmacological treatment for ankylosing spondylitis (AS)?

A
  • 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)

BRS MUSCULOSKELETAL And RHEUM (17 decks)

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