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Rhuematology > Back Pain > Flashcards

Back Pain Flashcards

1
Q

Classification of joints

A
  • Structural
  • Functional
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2
Q

Structural classification

A

2 criteria

  • the presence or absence of a synovial cavity
  • the type of connective tissue present

Three types

  • Fibrous
  • cartilaginous
  • synovial
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3
Q

Fibrous/ synathroses

A

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
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4
Q

Cartilaginous joint / ampithroses

A

No cavity, cartilaginous connective tissue

Examples

  • synchondroses - epiphseal growth plate
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5
Q

Synovial joint/ diathroses

A

cavity present, bones united by articular capsule

Examples

  • hip
  • wrist
  • knee
  • elbow
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6
Q

Functional classification

A

relates to the degree of movement permitted:

  • synathroses - immovable
    • sutures, gomphoses, synchondroses
  • amphiatrosis - slghtly movable
    • syndesmoses, symphyses
  • diarthroses- freely moveable
    • all synovial
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7
Q

Features of a synovial joint

A
  • 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
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8
Q

Types of movement

A
  • linear - gliding
  • angular - flexion, extension, abduction, adduction
  • rotational- medial, lateral, pronation, supination
  • special- inversion, eversion, protraction, retraction
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9
Q

Definitions of acute, subacute and chronic back pain

A
  • acute- <6 weeks
  • subacute - 6-12 weeks
  • chronic >12 weeks
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10
Q

Features of inflammatory back pain

A
  • 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
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11
Q

Causes of mechanical back pain

A
  • Minor injury
  • fracture
  • prolapsed disc
  • spondylosis
  • spinal stenosis
  • congenital
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12
Q

Non mechanical causes of back pain

A
  • Tumour
  • infective
  • sponylitis
  • pagets
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13
Q

Extra=spinal causes of back pain

A
  • renal calculi
  • pelvc inflamm
  • pancreatitis
  • aortic aneurysm
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14
Q

Mechanical back pain definition

A

MSK back pain is not a single specific disease entity but rather a collection of ill-defined conditions presenting with low back pain.

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15
Q

Features of mechanical back pain

A
  • 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
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16
Q

Red flags that suggest serious spinal pathology

A
  • 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
    *
17
Q

Yellow flags

A

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

18
Q

Definition of prolapsed intervertebral disc

A

A disc prolapse occurs when part of the nucelus pulposus herniates through the annulus fibrosus and presses on a spinal nerve root

19
Q

Clinical features of prolapsed intervertebral disc

A
  • 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
20
Q

Treatment of prolapsed disc

A

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

21
Q

Definiton of spondylolisthesis

A

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)

22
Q

Clinical features of spondylolisthesis

A
  • Back pain in adolescence
  • tenderness over the spine but well preserved movements
23
Q

Treatment of spondylolisthesis

A

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
24
Q

Spinal stenosis definition

A

Spinal stensosis is caused by degenerative changes narrowing the spinal canal and causing compression of the nerve roots

25
Q

Clinical features of spinal stenosis

A
  • discomfort when walking with pain referred to the buttock, calves and feet
  • back pain
  • pain worse on extension and relieved by rest and flexion of the spine
  • negative SLR test
26
Q

Treatment of spinal stenosis

A

Conservative

  • weight loss, physiotherapy, activity modifications and NSAIDS

Surgical

  • severe symptoms and not responding to conservative measures requiring surgical decompression
27
Q

Discitis/Vertebral osteomyelitis definition

A

Discitis - infection of the disc space

Vertebral osteomyelitis - infection of a vertebral body

28
Q

Clinical features of discitis

A
  • systemic signs of infection
  • ESR often raised
  • pain and movement restricted by spasm
29
Q

Treatment of discitis

A

Conservative

  • IV antibiotics are given for 6 weeks wiith a prolnged course of oral Abx if required

Surgical

  • Abscesses drained and unstable spine with significant deformitis
30
Q

Appropriate plan of investigations for back pain

A

Blood tests

  • WCC (infection)
  • CRP and ESR (malignancy, infection, inflammatory eg ank spond)
  • Haemoglobin (normocytic anaemia in chronic inflammation/infection/myeloma)
  • Calcium studies (bony mets, myeloma)
  • Immunoglobulins and electrophoresis (myeloma)
  • Alkaline phosphatase (mets, pagets)
  • HLA B27 (ank spond)

X ray - fractures

MRI – cauda equina, malignancy, spinal infection

31
Q

Basic approach to the management of back pain

A
  • Education – reassurance again significant underlying pathology, warn that recurrent common, use neutral terms – ‘sprain’/ ‘strain’, encourage them to take responsibility for recovery
  • Activity – discourage bed rest, encourage back to work and normal activity
  • Medication – paracetamol, NSAID, weak opioid if needed, tricyclics – especially useful for neuropathic pain
  • Physical therapy – structured exercise programmes, acupuncture, spinal manipulation, rehab – combination of physical and psychological
  • Surgery – if ongoing pain after rehab programme
32
Q

Prevention of back pain

A
  • Exercise
  • Weight loss
  • Stop smoking
  • Temporary job modification
33
Q

Definitions

Spondylolysis

Spondylosis

Spondylitis

Radiculopathy

A

Spondylolysis - Spondylolysis is a defect of a vertebra. More specifically it is defined as a defect in the pars interarticularis of the vertebral arch.

Spondylosis - Degeneration/ Osteoarthritis of the interverbral discs

Spondylitis - inflammation of vertebral body

Radiculopathy - A condition where one or more spinal nerves are compressed

Rhuematology (18 decks)

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