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Orthopaedics > Back Pain > Flashcards

Back Pain Flashcards

1
Q

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

A 
Insomnia
Out of pocket expenses 
Emotional stress
Relationship breakdowns 
Severe emotional distress for the partner
Limitations in fulfilling family tasks
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2
Q

When does acute back pain become chronic?

A

When the person has had it for 3 months or longer

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3
Q

What is the most common cause of back pain?

A

‘Wear-and-tear’

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4
Q

What are the three main categories of back pain?

A

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

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5
Q

Describe the specific features of mechanical back pain.

A

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

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6
Q

What are the causes of mechanical back pain?

A 
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
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7
Q

Briefly describe degenerative disk disease (spondylosis).

A

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

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8
Q

Briefly describe degenerative facet joint disease.

A

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

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9
Q

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

A

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

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10
Q

Describe how a person with a disc prolapse would present.

A

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

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11
Q

What investigations/treatments are done for disc prolpse?

A

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

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12
Q

What is spinal stenosis?

A

Anatomical narrowing of the spine

  • congenital and/or degenerative
  • can cause cord compression syndrome by spinal canal compression on the cord
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13
Q

How does spinal stenosis present.

A

Claudication in legs/calves

- worse when walking, rested in the flexed position

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14
Q

How is spinal stenosis claudication different from that of PVD?

A

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

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15
Q

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

A

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

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16
Q

Describe the symptoms of cauda equina syndrome.

A 
Neuropathic symptoms (bilateral sciatica and saddle anaesthesia) 
Bladder or bowel dysfunction (reduced anal tone)
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17
Q

What causes cauda equina syndrome?

A

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

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18
Q

What is spondylothisthesis?

A

A bone in the spine slips either forward or backwards

19
Q

Describe the symptoms of spondylothisthesis.

A 
Lower back pain
Numbness and tingling from lower back and down the legs 
Pain in posterior thigh 
Excessive kyphosis 
Pain increases with extension
20
Q

What is a compression fracture and how does it present?

A

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

21
Q

How is a compression fracture treated?

A 
Conservative (analgesia)
Bisphosphonates 
Calcitonin - helps with the pain
Surgery 
- vertebroplasty (cement)
- kyphoplasty (balloon)
22
Q

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

A 
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
23
Q

What are the systemic causes of back pain?

A

Infection - discitis, osteomyelitis and epidural abscess
Malignancy
Inflammation

24
Q

What is infective discitis?

A

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

25
Q

What are the presenting symptoms of infective discitis?

A

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

26
Q

How is infective discitis diagnosed?

A 
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
27
Q

How is infective discitis managed?

A

IV antibiotics with or without surgical debridement

28
Q

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

A

LP Thomas Knows Best

  • lung
  • prostate
  • thyroid
  • kidney
  • breast
29
Q

What are the signs and symptoms of malignancy?

A 
Constant pain
- worse at night
Systemic symptoms
Weight loss
Night sweats
Primary tumour signs and symptoms
30
Q

How is vertebral malignancy diagnosed and managed?

A 
X-Ray
- lytic (bone being dissolved) and destructive changes 
- only affects on vertebrae 
MRI
Bone scan
Looks for the primary
- treat
31
Q

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

A

Under the age of 45

- often in the teens

32
Q

What are the symptoms of inflammatory back pain?

A

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

33
Q

What causes inflammatory back pain?

A

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

34
Q

What are ‘red flag’ symptoms of back pain?

A 
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
35
Q

What are the yellow flags of back pain?

A

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

36
Q

What are the differences between mechanical and inflammatory back pain?

A

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

37
Q

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

A

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

38
Q

What is ankylosing spondylitis?

A

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

39
Q

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

A

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

40
Q

How is ankylosing spondylitis diagnosed?

A

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

41
Q

What other inflammatory conditions are associated with ankylosing spondylitis?

A 
Undifferentiated SpA
Psoriatic arthritis 
Acute anterior uveitis 
Reactive arthritis 
Arthritis associated with IBD
Juvenile SpA
42
Q

What are the symptoms of ankylosing spondylitis?

A 
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
43
Q

Why do people get ankylosing spondylitis?

A 
Genetics = susceptibility 
- HLA-B27
Environment
- infection
- microbiome in the gut and skin
Biomechanics
44
Q

How is ankylosing spondylitis managed?

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

Orthopaedics (13 decks)

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