Back pain Flashcards
What’s mechanical back pain?
Soft tissue injury → muscle spasm → pain
- May have inciting event: e.g. lifting
- Younger ptients with no sinister features
Management of mechanical back pain
Conservative
- Max 2d bed rest
- Education: keep active, how to lift / stoop
- Physiotherapy
- Psychosocial issues re. chronic pain and disability
- Warmth: e.g. swimming in a warm pool
Medical
- Analgesia: paracetamol ± NSAIDs ± codeine
- Muscle relaxant: low-dose diazepam (short-term)
Suspicious features of back pain
Suspicious (tumours and acute compressions)
- bladder and bowel symptoms, saddle anaesthesia (buttocks), new bilateral sciatica → red flags of spinal compression
- age <20 or >50 (acute onset in the elderly)
- weight loss (malignancy)
- fever (infection)
- active cancer; Hx of cancer
- recent bacterial infection
- night/rest pain
- back pain that persist for more than 3 months
What’s spondylolisthesis?
Displacement of one lumbar vertebra on another
- Usually forward
- Usually L5 on S1
- May be palpable
Causes of spondylolisthesis
Causes
- Congenital malformation
- Spondylosis
- Osteoarthritis
Presentation of spondylolisthesis
- Onset of pain usually in adolescence or early adulthood
- Worse on standing
- ± sciatica, hamstring tightness, abnormal gait
Ix of spondylolisthesis
Plain radiography
Management of spondylolisthesis
- Corset
- Nerve release
- Spinal fusion
What’s spinal stenosis
Developmental predisposition ± facet joint
osteoarthritis → generalized narrowing of lumbar
spinal canal (caused by osteophytes formation and osteoarthritis)
Presentation of spinal stenosis
- Spinal claudication → aching or heavy buttock and lower limb pain on exercise/walking
- Rapid onset
- May c/o paraesthesiae/numbness
- Pain eased by leaning forward (e.g. on bike)
- Pain on spine extension
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Management of spinal stenosis
- Corsets
- NSAIDs
- Epidural steroid injection
- Canal decompression surgery (removal of osteophytes)
Investigation of spinal stenosis
MRI
Ix for Ankylosing spondylitis
- ESR, CRP → typically raised although normal levels do not exclude ankylosing spondylitis
- HLA-B27 is of little use in making the diagnosis as it is positive in: 90% of patients with ankylosing spondylitis; 10% of normal patients)
- x-ray of the sacroiliac joints → the most useful investigation in establishing the diagnosis
- Spirometry → may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints
What can be seen on X-ray in Ankylosing Spondylitis?
Radiographs may be normal early in disease, later changes include:
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- chest x-ray: apical fibrosis
What’s Ankylosing Spondylitis?
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy (type of arthritis.
Presentation of Ankylosing Spondylitis
- typically presents in males (sex ratio 3:1)
- 20-30 years old
- lower back pain and stiffness
- insidious onset
- stiffness is usually worse in the morning and improves with exercise
- patient may experience pain at night which improves on getting up
Management of Ankylosing Spondylitis
- encourage regular exercise such as swimming
- NSAIDs → first-line treatment
- physiotherapy
- disease-modifying drugs which are used to treat RA e.g. sulphasalazine → only useful if there is peripheral joint involvement
- Anti-TNF therapy → should be given to patients with persistently high disease activity despite conventional treatments
Features possibly seen on clinical examination in Ankylosing Spondylitis
- reduced lateral flexion
- reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
- reduced chest expansion
What’s Pott’s disease?
Infection of intravertebral disc
- it causes kyphosis
