Back Pain

Question 1

How can chronic back pain be a burden on the patient?

Answer 1

Insomnia
Out of pocket expenses 
Emotional stress
Relationship breakdowns 
Severe emotional distress for the partner
Limitations in fulfilling family tasks

Question 2

When does acute back pain become chronic?

Answer 2

When the person has had it for 3 months or longer

Question 3

What is the most common cause of back pain?

Answer 3

‘Wear-and-tear’

Question 4

What are the three main categories of back pain?

Answer 4

Mechanical (97%) - non specific lower back pain
Systemic
Referred - the pathology isn’t in the back (most commonly abdominal pathology)

Question 5

Describe the specific features of mechanical back pain.

Answer 5

Onset at any age
Generally worsens with movement or prolonged standing
Better with rest
Early morning stiffness that eases within 30 minutes

Question 6

What are the causes of mechanical back pain?

Answer 6

Lumbar strain/sprain 
- most common, affecting many people 
- causes acute muscle spasms that resolve within 24-48 hours 
Degenerative disks/facet jointsBe
Disc prolapse, spinal stenosis 
Compression fracture

Question 7

Briefly describe degenerative disk disease (spondylosis).

Answer 7

Painful thinning of the IV disks
Pain increases with flexion, sitting and sneezing
- this increases pressure in the abdomen

Question 8

Briefly describe degenerative facet joint disease.

Answer 8

Degeneration and pain at the articulation between two spinal vertebrae
- facet joint arthritis
More localised
Pain increases with extension

Question 9

How would you would manage non-specific lower back pain?

Answer 9

Keep diagnosis under review - in case something more sinister is happening
Promote self managment
- advise to stay active (the quicker you can mobilise the better)
Exercise programme and physiotherapy
Analgesics (avoid opiates)
Acupuncture

Question 10

Describe how a person with a disc prolapse would present.

Answer 10

May be acute, increase cough - sneezing is a common precipitating cause
Typically leg pain (sciatica - radiculopathy)
- straight leg raising test
Reduced reflexes
Spontaneous resolve within 12 weeks

Question 11

What investigations/treatments are done for disc prolpse?

Answer 11

X-Ray (MRI if nothing can be seen)
Most resolve by themselves, but <10% need surgery
- surgery not done before 12 weeks as most people’s pain stops before then
- removal of the disk

Question 12

What is spinal stenosis?

Answer 12

Anatomical narrowing of the spine

• congenital and/or degenerative
• can cause cord compression syndrome by spinal canal compression on the cord

Question 13

How does spinal stenosis present.

Answer 13

Claudication in legs/calves

- worse when walking, rested in the flexed position

Question 14

How is spinal stenosis claudication different from that of PVD?

Answer 14

PVD - equal on both sides, often not associated with back pain and pulses are not present

Question 15

Why does surgery for spinal stenosis carry such a high risk?

Answer 15

Carries risk of paralysis due to close proximity to the spinal cord
Generally not done unless the patient is starting to loss function of their legs anyway

Question 16

Describe the symptoms of cauda equina syndrome.

Answer 16

Neuropathic symptoms (bilateral sciatica and saddle anaesthesia) 
Bladder or bowel dysfunction (reduced anal tone)

Question 17

What causes cauda equina syndrome?

Answer 17

Compression of the cauda equina - most commonly caused by a large disk prolapse

Question 18

What is spondylothisthesis?

Answer 18

A bone in the spine slips either forward or backwards

Question 19

Describe the symptoms of spondylothisthesis.

Answer 19

Lower back pain
Numbness and tingling from lower back and down the legs 
Pain in posterior thigh 
Excessive kyphosis 
Pain increases with extension

Question 20

What is a compression fracture and how does it present?

Answer 20

Type of fracture commonly seen in osteoporosis
- seen mainly in elderly patients
- causes shortening and curving of the spine
Vertebrae shrinks
Pain is sudden, severe and radiates in a belt around the chest/abdomen
- pain settles within three weeks

Question 21

How is a compression fracture treated?

Answer 21

Conservative (analgesia)
Bisphosphonates 
Calcitonin - helps with the pain
Surgery 
- vertebroplasty (cement)
- kyphoplasty (balloon)

Question 22

Name some causes of back pain that have been referred from reteroperitoneal structures.

Answer 22

Aortic aneurysm 
- pulsating abdominal mass
Acute pancreatitis
- epigastric pain, relief leaning forward 
Peptic ulcer disease
- epigastric pain after food
Acute pyelonephritis/renal colic 
- haematuria and radiating pain

Question 23

What are the systemic causes of back pain?

Answer 23

Infection - discitis, osteomyelitis and epidural abscess
Malignancy
Inflammation

Question 24

What is infective discitis?

Answer 24

Inflammation that develops between the IV discs of the spine (in the IV disk spaces)
- swelling in these spaces put pressure on the discs and causes pain
Most commonly caused by a Staph Aureus infection
Can sometimes causes abscesses which increases pressure on the bone

Question 25

What are the presenting symptoms of infective discitis?

Answer 25

Fever Weight loss Constant back pain - during rest and worse at night

Question 26

How is infective discitis diagnosed?

Answer 26

``` Bloods (FBC, ESR, CRP and cultures) X-Ray (end-plate/vertebral destruction) - no disc spaces visible - damage on both sides of the disc (unlike bone which causes unilateral damage) MRI - oedematous discs Aspiration ```

Question 27

How is infective discitis managed?

Answer 27

IV antibiotics with or without surgical debridement

Question 28

What are the most common cancers to metastasise to the spine?

Answer 28

LP Thomas Knows Best - lung - prostate - thyroid - kidney - breast

Question 29

What are the signs and symptoms of malignancy?

Answer 29

``` Constant pain - worse at night Systemic symptoms Weight loss Night sweats Primary tumour signs and symptoms ```

Question 30

How is vertebral malignancy diagnosed and managed?

Answer 30

``` X-Ray - lytic (bone being dissolved) and destructive changes - only affects on vertebrae MRI Bone scan Looks for the primary - treat ```

Question 31

What age is most common for the onset of inflammatory back pain?

Answer 31

Under the age of 45 | - often in the teens

Question 32

What are the symptoms of inflammatory back pain?

Answer 32

Early morning stiffness that lasts over 30 minutes - stiff after rest, improves with movement - may wake them up in the night Inflammatory symptoms

Question 33

What causes inflammatory back pain?

Answer 33

IBP is a symptom in itself, not a diagnosis Ankylosing Spondylitis Axial spondyloarthritis

Question 34

What are 'red flag' symptoms of back pain?

Answer 34

``` Onset under the age of 16 and over the age of 50 Following significant trauma Previous malignancy Systemic symptoms - fever, rigors, general malaise and weight loss Previous steroid use - increase likelihood of a stress fracture IVDU, HIV or immunocompromised - increases likelihood of infection Recent significant infection Urinary retention - cauda equina syndrome Non-mechanical pain (worse at rest) Thoracic spine pain - rare (not weight bearing or flexible) Saddle anaesthesia Reduced anal tone Hip/knee weakness General neurological deficit Progressive spinal deformity ```

Question 35

What are the yellow flags of back pain?

Answer 35

Bio-psycho social model (patient is more likely to develop a chronic problem) Attitudes Beliefs - misguided, think they have something serious Compensation Diagnosis - misunderstanding what is wrong with them Emotions - depression, etc Family - over/under supportive Work

Question 36

What are the differences between mechanical and inflammatory back pain?

Answer 36

IBP - lower age of onset, chronic onset, pain improves with movement, pain gets worse with rest/at night and morning stiffness takes under 30 minutes to resolve MBP - can onset at any age, acute onset, pain worse with movement, pain improves with rest and morning stiffness lasts over 30 minutes

Question 37

Ankylosing spondylitis is diagnosed if there is the radiological criterion and at least one clinical criterion. What are the radiological and clinical criteria?

Answer 37

Clinical - lower back pain and stiffness for more than three months that improves with exercise, and not relieved by rest - limitation of movement of the lumbar spine in both the sagittal and frontal planes - limitation of chest expansion relative to norrmal values for age and sex Radiological - sacroilitis grade 2 or more bilaterally or grade 3-4 unilaterally

Question 38

What is ankylosing spondylitis?

Answer 38

A type of arthritis that causes long term inflammation of the joint of the spine - typically where the spine joins the pelvis (sarcolilitis)

Question 39

What can you see on an X-Ray with ankylosing spondylitis?

Answer 39

Often nothing, especially in early disease Late disease - erosions which progress to pseudo-widening of the joint space and bone ankylosis - sclerosis (syndesmophytes form as the body tries to fix the problem, and soon these bridge and cause vertebral fusion) - bone marrow oedema

Question 40

How is ankylosing spondylitis diagnosed?

Answer 40

X-Ray - late stages MRI - all stages - not often done early so AS takes a long time to diagnose

Question 41

What other inflammatory conditions are associated with ankylosing spondylitis?

Answer 41

``` Undifferentiated SpA Psoriatic arthritis Acute anterior uveitis Reactive arthritis Arthritis associated with IBD Juvenile SpA ```

Question 42

What are the symptoms of ankylosing spondylitis?

Answer 42

``` Inflammatory back pain Fatigue Arthritis in other joints, hips and knees Enthesitis (achilles tendon, plantar fasciitis) Inflammation outside the joints - uveitus - psoriasis - IBD - osteoporosis Family history of the above ```

Question 43

Why do people get ankylosing spondylitis?

Answer 43

``` Genetics = susceptibility - HLA-B27 Environment - infection - microbiome in the gut and skin Biomechanics ```

Question 44

How is ankylosing spondylitis managed?

Answer 44

``` NSAIDs Education, exercise, physical therapy, self help groups etc Sulfasalazine Local corticosteroids TNF blockers Analgesics Surgery ```