back pain

Question 1

how long does back pain have to be to be chronic

Answer 1

3 months or more

Question 2

what are the thee causes of chronic back pain

Answer 2

1. Mechanical (97%) – non-specific low back pain (NSLBP)
2. Systemic
   a) Infection
   b) Malignancy
   c) Inflammatory
3. Referred (i.e. no pathology in back)

Question 3

give some causes of NSLBP

Answer 3

– Lumbar strain/sprain
– Degenerative discs/facets joints
– Disc prolapse, spinal stenosis
– Compression fractures

Question 4

what may cause a radiculopathy in the case of lower back pain

Answer 4

a herniated nucleous pulposus impinging on the spinal nerve root

Question 5

how does spinal stenosis typically present?

Answer 5

claudication in legs/calves

Worse when walking. Get some rest when they are in a flexed position.

Question 6

what sort of reflexes would you expect in someone who had a herniated disc

Answer 6

reduced

Question 7

what sort of reflexes would you expect in someone with a cervical disc pressing on the spinal cord

Answer 7

brisk

Question 8

how would you describe the pain in a compression fracture

Answer 8

• Radiates in “belt” around chest/abdomen

– Dermatomal spread

Question 9

what are the treatment options for a compression fracture

Answer 9

– Conservative (analgesia)

– Vertebroplasty (cement) or kyphoplasty (balloon)

Question 10

name some causes of referred back pain

Answer 10

– Aortic aneurysm
 CVS features (BP, ↑HR), collapse, pulsa􀆟ng abdo mass
– Acute pancreatitis
 Epigastric pain, relief lean forwards, unwell
– Peptic ulcer disease (duodenal)
 Epigastric pain (meals), history PUD, vomit, blood/malaena
– Acute pyelonephritis/ Renal colic
 History UTI/stones, unwell, radiation, haematuria, frequency
– Endometriosis/gynae

Question 11

in which patients should you consider a diagnosis of infective discitis

Answer 11

Immunosuppressed, diabetes, IV drug users

Question 12

how would you treat infective discitis

Answer 12

IV antibiotics +/- debridement

Question 13

which cancers most commonly metastasise to bone

Answer 13

Lung, prostate, thyroid, kidney, breast (LP Thomas Knows Best)

Question 14

describe inflammatory back pain

Answer 14

• Onset <45 years (often teens)
• Early morning stiffness >30mins
• Back stiff after rest & improves with movement
• May wake 2nd half night, buttock pain

Question 15

what are the symptom red flags for back pain

Answer 15

–	New onset age <16 or >50
–	Following significant trauma
–	Previous malignancy
–	Systemic = fevers/rigors, general malaise, weight loss
–	Previous steroid use
–	IV drug abuse, HIV or immunosuppressed
–	Recent significant infection
–	Urinary retention
–	Non-mechanical pain - worse at rest “night pain”
–	Thoracic spine pain

Question 16

what are the signs that are red flags in back pain

Answer 16

–	Saddle anaesthesia
–	Reduced anal tone
–	Hip or knee weakness
–	Generalised neurological deficit
–	Progressive spinal deformity

Question 17

what is spondylosis

Answer 17

a name given to the degenerative disease of the inter-vertebral discs

Question 18

name 3 major differences between mechanical and inflammatory back pain

Answer 18

In mechanical exercise makes the pain worse but in inflammatory it makes it better.
Rest often improves mechanical back pain, it does nothing for inflammatory
Morning stiffness usually lasts less than a half an hour in mechanical, it is usually longer in inflammatory
Mechanical often improves at night but in inflammatory they often wake up in the 2nd half of the night

Question 19

what is spondylolisthesis

Answer 19

where one vertebra slips on the one below. Often due to a pars interarticularis defect.
Pain may radiate to the posterior thigh and increaase with extension.

Question 20

describe the symptoms in ank spond

Answer 20

• Patients typically present with gradual onset of lower back pain and stiffness
• Symptoms worse in morning and after long periods of rest. Usually improve with exercise

Question 21

describe signs in ank spond

Answer 21

o SI joints are often tender and pain can be elicited by applying pressure on the anterior superior iliac spine while patient is lying supine
o Reduced mobility of the lumbar spine
 Make mark on skin at lumbosacral joint and ask to touch toes without bending knees
 Second line drawn 10 cm above the other one
 Distance between the two should increase by at least 5cm
o Lateral flexion of spine is painful/limited

Question 22

what features may you see on imaging in ank spond

Answer 22

o Sclerosis – shiny corners
o Syndesmophytes – bony growth originating inside a ligament. Seen in the ligaments in the intervertebral joints leading to fusion of the vertebrae
o Spondylophytes – bony spur (osteophyte of the spine)
o Bridging syndesmophytes

Question 23

What are the symptoms of axial spondyloarthritis

Answer 23

o Inflammatory back pain
o Fatigue
o Arthritis in other joints: hips, knees
o Enthesitis: Achilles tendon, plantar fasciitis
o Inflammation outside joints = extra-articular:
 Eye: Uveitis
 Skin: Psoriasis
 Bowel: Crohn’s disease/ulcerative colitis
 Other: heart, lungs, osteoporosis
o Family history of above

Question 24

which HLA is implicated in the genetics of axial spondyloarthritis

Answer 24

HLA-B27

Also associations with the IL-23 R and IL-17A pathway

Question 25

name a mimic of sacro-iliitis on MRI

Answer 25

infection - will have inflammation on both sides of the joint
insufficiency fracture