Back Pain Flashcards
How can chronic back pain be a burden on the patient?
Insomnia Out of pocket expenses Emotional stress Relationship breakdowns Severe emotional distress for the partner Limitations in fulfilling family tasks
When does acute back pain become chronic?
When the person has had it for 3 months or longer
What is the most common cause of back pain?
‘Wear-and-tear’
What are the three main categories of back pain?
Mechanical (97%) - non specific lower back pain
Systemic
Referred - the pathology isn’t in the back (most commonly abdominal pathology)
Describe the specific features of mechanical back pain.
Onset at any age
Generally worsens with movement or prolonged standing
Better with rest
Early morning stiffness that eases within 30 minutes
What are the causes of mechanical back pain?
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
Briefly describe degenerative disk disease (spondylosis).
Painful thinning of the IV disks
Pain increases with flexion, sitting and sneezing
- this increases pressure in the abdomen
Briefly describe degenerative facet joint disease.
Degeneration and pain at the articulation between two spinal vertebrae
- facet joint arthritis
More localised
Pain increases with extension
How would you would manage non-specific lower back pain?
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
Describe how a person with a disc prolapse would present.
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
What investigations/treatments are done for disc prolpse?
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
What is spinal stenosis?
Anatomical narrowing of the spine
- congenital and/or degenerative
- can cause cord compression syndrome by spinal canal compression on the cord
How does spinal stenosis present.
Claudication in legs/calves
- worse when walking, rested in the flexed position
How is spinal stenosis claudication different from that of PVD?
PVD - equal on both sides, often not associated with back pain and pulses are not present
Why does surgery for spinal stenosis carry such a high risk?
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
Describe the symptoms of cauda equina syndrome.
Neuropathic symptoms (bilateral sciatica and saddle anaesthesia) Bladder or bowel dysfunction (reduced anal tone)
What causes cauda equina syndrome?
Compression of the cauda equina - most commonly caused by a large disk prolapse
What is spondylothisthesis?
A bone in the spine slips either forward or backwards
Describe the symptoms of spondylothisthesis.
Lower back pain Numbness and tingling from lower back and down the legs Pain in posterior thigh Excessive kyphosis Pain increases with extension
What is a compression fracture and how does it present?
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
How is a compression fracture treated?
Conservative (analgesia) Bisphosphonates Calcitonin - helps with the pain Surgery - vertebroplasty (cement) - kyphoplasty (balloon)
Name some causes of back pain that have been referred from reteroperitoneal structures.
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
What are the systemic causes of back pain?
Infection - discitis, osteomyelitis and epidural abscess
Malignancy
Inflammation
What is infective discitis?
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
What are the presenting symptoms of infective discitis?
Fever
Weight loss
Constant back pain
- during rest and worse at night
How is infective discitis diagnosed?
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
How is infective discitis managed?
IV antibiotics with or without surgical debridement
What are the most common cancers to metastasise to the spine?
LP Thomas Knows Best
- lung
- prostate
- thyroid
- kidney
- breast
What are the signs and symptoms of malignancy?
Constant pain - worse at night Systemic symptoms Weight loss Night sweats Primary tumour signs and symptoms
How is vertebral malignancy diagnosed and managed?
X-Ray - lytic (bone being dissolved) and destructive changes - only affects on vertebrae MRI Bone scan Looks for the primary - treat
What age is most common for the onset of inflammatory back pain?
Under the age of 45
- often in the teens
What are the symptoms of inflammatory back pain?
Early morning stiffness that lasts over 30 minutes
- stiff after rest, improves with movement
- may wake them up in the night
Inflammatory symptoms
What causes inflammatory back pain?
IBP is a symptom in itself, not a diagnosis
Ankylosing Spondylitis
Axial spondyloarthritis
What are ‘red flag’ symptoms of back pain?
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
What are the yellow flags of back pain?
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
What are the differences between mechanical and inflammatory back pain?
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
Ankylosing spondylitis is diagnosed if there is the radiological criterion and at least one clinical criterion. What are the radiological and clinical criteria?
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
What is ankylosing spondylitis?
A type of arthritis that causes long term inflammation of the joint of the spine
- typically where the spine joins the pelvis (sarcolilitis)
What can you see on an X-Ray with ankylosing spondylitis?
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
How is ankylosing spondylitis diagnosed?
X-Ray - late stages
MRI - all stages
- not often done early so AS takes a long time to diagnose
What other inflammatory conditions are associated with ankylosing spondylitis?
Undifferentiated SpA Psoriatic arthritis Acute anterior uveitis Reactive arthritis Arthritis associated with IBD Juvenile SpA
What are the symptoms of ankylosing spondylitis?
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
Why do people get ankylosing spondylitis?
Genetics = susceptibility - HLA-B27 Environment - infection - microbiome in the gut and skin Biomechanics
How is ankylosing spondylitis managed?
NSAIDs Education, exercise, physical therapy, self help groups etc Sulfasalazine Local corticosteroids TNF blockers Analgesics Surgery
