Back Pain Flashcards
Classification of joints
- Structural
- Functional
Structural classification
2 criteria
- the presence or absence of a synovial cavity
- the type of connective tissue present
Three types
- Fibrous
- cartilaginous
- synovial
Fibrous/ synathroses
No cavity, fibrous connective tissue
examples
- Sutures - bones of the skull
- Syndesmoses - band or ligament, distal tibiofibular joint
- Gomphoses - tooth in gum
- interosseous membrane- between ther radius and ulna
Cartilaginous joint / ampithroses
No cavity, cartilaginous connective tissue
Examples
- synchondroses - epiphseal growth plate
Synovial joint/ diathroses
cavity present, bones united by articular capsule
Examples
- hip
- wrist
- knee
- elbow
Functional classification
relates to the degree of movement permitted:
- synathroses - immovable
- sutures, gomphoses, synchondroses
- amphiatrosis - slghtly movable
- syndesmoses, symphyses
- diarthroses- freely moveable
- all synovial
Features of a synovial joint
- synovial cavity that allows free movement
- articular surfaces covered with hyaline cartilage (articular cartilage)
- ECM containing chondrocytes
- avascular
- surrrounded by articular capsule
- outer fibrous capsule
- inner synovial membrane
- synovial membane - secretes synovial fluid
- accesory structures- ligaments, tendons, menisci, fat pads, bursae
Types of movement
- linear - gliding
- angular - flexion, extension, abduction, adduction
- rotational- medial, lateral, pronation, supination
- special- inversion, eversion, protraction, retraction
Definitions of acute, subacute and chronic back pain
- acute- <6 weeks
- subacute - 6-12 weeks
- chronic >12 weeks
Features of inflammatory back pain
- young age of onset <40
- insidious onset
- morning stiffness for >30 minutes
- better with exercise
- worse or no improvement with rest
- waking in the night particularly second half of nght
- alternating buttock pain
- improvement with anti-inflammatory medicines e.g NSAIDS
Causes of mechanical back pain
- Minor injury
- fracture
- prolapsed disc
- spondylosis
- spinal stenosis
- congenital
Non mechanical causes of back pain
- Tumour
- infective
- sponylitis
- pagets
Extra=spinal causes of back pain
- renal calculi
- pelvc inflamm
- pancreatitis
- aortic aneurysm
Mechanical back pain definition
MSK back pain is not a single specific disease entity but rather a collection of ill-defined conditions presenting with low back pain.
Features of mechanical back pain
- History of lifting or straining
- pain is worse on movement and activity (Mechanical pain)
- band across the back and may be severe
- RED FLAGS
- yellow flags
Red flags that suggest serious spinal pathology
- age of onset <20 or >55
- acute onset in elderly
- constant or progressive pain
- nocturnal pain
- worse pain on being supine
- fever, night sweats, weight loss
- history of malignancy
- abdominal mass
- thoracic back pain
- morning stiffness
- bilateral or alternating leg pain
- neurological distrubance (incl sciatica)
- spincter disturbance
- current or recent infection
- immunosuppression
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Yellow flags
Attitudes - towards the current problem. Does the patient feel that with appropriate help and self management they will return to normal activities?
Beliefs - The most common misguided belief is that the patient feels they have something serious causing their problem-usually cancer. ‘Faulty’ beliefs can lead to catastrophisation.
Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA?
Diagnosis - or more importantly Iatrogenesis. Inappropriate communication can lead to patients misunderstanding what is meant, the most common examples being ‘your disc has popped out’ or ‘your spine is crumbling’.
Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxietous states are at a high risk of developing chronic pain.
Family - There tends to be two problems with families, either over bearing or under supportive.
Work - The worse the relationship, the more likely they are to develop chronic LBP
Definition of prolapsed intervertebral disc
A disc prolapse occurs when part of the nucelus pulposus herniates through the annulus fibrosus and presses on a spinal nerve root
Clinical features of prolapsed intervertebral disc
- Sciatica - severe oain radiating down the leg as far as toes
- Coughing and sneezing worsens the pain
- Abnormal posute - stooping to the affected side and standing with the knee flexed to relieve pressure on the dura
- SLR test positive
- Numbness in dermatomal distrubution and weakness
Treatment of prolapsed disc
Conservatve
- short period of bed rest + gentle physiotherapy + adequate analgesia
Surgical
- only indication is cauda equina syndrome and progessively worseinging neurological deficit
- proloonged iretractable back pain (>9 months) then surgery
Let patients know that 70% of acute disc prolapses settle spontaneously with conservative treatment
Definiton of spondylolisthesis
Means sliping of one vertebral body onto another (mainly L5)
Note - Spondylolysis - defect in pars interarticularis which may allow the vertebra to slip forward, causing a sponylolisthesis (forward slippage of one vertebrae on another)
Clinical features of spondylolisthesis
- Back pain in adolescence
- tenderness over the spine but well preserved movements
Treatment of spondylolisthesis
Conservative
- inital rest and restriction of activites may allow spondylolysis to heal before a slip occurs
- in adults trial of conservative treatment
Surgical
- peristant pain, radiculopathy and significant deformity - indications for surgery
Spinal stenosis definition
Spinal stensosis is caused by degenerative changes narrowing the spinal canal and causing compression of the nerve roots
