Back pain

Question 1

common sites of the spine for degenerative spinal disease

Answer 1

cervical and lumbar area

Question 2

medication that requires DEXA scan monitoring, and why

indication for medication

Answer 2

aromatase inhibitors; lower oestrogen levels which can accelerate bone loss

indicated in previous history of breast cancer

Question 3

management by GP for suspected metastatic spinal cord compression

Answer 3

urgent (24-48 hours) MRI whole spine

Question 4

7 symptoms suggestive of metastatic spinal cord compression

Answer 4

• progressive pain in spine
• severe unremitting spinal pain
• spinal pain aggravated by straining e.g. cough, sneeze, moving
• band like pain
• local spinal tenderness
• nocturnal spinal pain preventing sleep
• neuro symptoms: radicular pain, limb weakness, walking difficulty, sensory loss, bowel/bladder dysfunction

Question 5

when should the MSCC coordinator be contacted

Answer 5

within 24 hours

Question 6

2 curative treatments

Answer 6

• surgery

- radical radiotherapy

Question 7

aim of palliative care?

Answer 7

• increase life expectancy

- improve symptoms now + in the future

Question 8

adjuvant therapy

Answer 8

• occurs following surgery that has been curative

- systemic treatment aimed at reducing the chance of relapse

Question 9

systemic treatment options for MSCC

Answer 9

• endocrine therapy
• chemotherapy
• HER2 targeted therapy
• bone targeted therapy

Question 10

further blood tests following MSCC

Answer 10

FBC: bone marrow infiltration can lead to bone marrow suppression: anaemia + thrombocytopenia

Bone profile: hypercalcaemia

U + E: if hypercalcaemia found

LFTs: marker for liver mets

Question 11

management of hypercalcemia from bone mets

Answer 11

1st line saline

2nd line IV bisphosphonate infusion

Question 12

what is vertebroplasty?

Answer 12

injecting cement into a collapsed vertebral body, to help with pain control

Question 13

Tamoxifen

Answer 13

selective oestrogen receptor modulator; which blocks receptors; preventing oestrogen from reaching them

Question 14

aromatase inhibitors

Answer 14

prevent conversion of androgens to oestrogens; therefore reducing the level of oestrogen in the blood to undetectable levels

only effective in post menopausal women

Question 15

hormonal treatments for ER positive cancer (3)

Answer 15

• Tamoxifen
• Aromatase inhibitors
• Fluvestrant

Question 16

drug to lower oestrogen levels in post menopausal women

Answer 16

Aromatase inhibitors

Fluvestrant

Question 17

% breast cancers that are Her2 positive

Answer 17

15

Question 18

combination 1st line trx for Her2 positive breast cancer

Answer 18

• Pertuzumab
• Trastuzumab
• Docetaxel (chemotherapy)

Question 19

mechanism of Trastuzumab

Answer 19

interacting with HER2 receptor and preventing it being stimulated by growth factors

Question 20

what can be affected by both Pertuzumab + Trastuzumab

and consequently what must be assessed

Answer 20

cardiac function

LVEF prior to starting and at regular intervals while they continue to receive them

Question 21

2 ways of measuring LVEF

Answer 21

• echo

- MUGA scan (multi gated acquisition scan… nuclear medicine scan)

Question 22

What is denosumab

Answer 22

monoclonal antibody, RANK ligand inhibitor

Question 23

denosumab can treat (2)

Answer 23

• metastatic cancers

- osteoporosis

Question 24

what is denosumab effective at reducing

Answer 24

skeletal related events e.g. fractures, spinal cord compression, need for interventional surgery or radiotherapy

Question 25

long term trx of bone mets

Answer 25

denosumab

Question 26

2 important side effects of denosumab

Answer 26

• hypocalcaemia

- jaw osteonecrosis

Question 27

Red flags in back pain

Answer 27

• previous hx malignancy
• age < 16 or > 50 years with new onset pain
• previous long standing steroid use
• recent serious illness
• recent significant infection

Question 28

red flag signs

Answer 28

• saddle anaesthesia
• reduced anal tone
• hip/knee weakness
• generalise spinal deformity
• urinary retention