Back pain Flashcards
ΔΔ back pain?
MECHANICAL:
• Disc herniation: can itself cause pain, or secondarily due to nerve root compression
• Trauma (can lead to sacroiliitis)
• Muscular pain
BONE
• Ankylosing spondylitis and other inflammatory arthropathies
• Osteoporotic vertebral crush.
• Paget’s disease of the bone.
• Primary or secondary bone cancer; often systemic symptoms too.
NEURO
• Cauda equina
• Spinal stenosis
• Nerve root compression
Hx: patient presents with bilateral, asymmetrical leg weakness, back pain, saddle (upper inner thigh)/perineal anaesthesia, bladder retention and incontinence?
+/- urinary overflow incontinence and constipation can also occur
Ex ↓reflexes
cauda equina syndrome
- lesions of the roots and nerves below the spinal cord, with LMN Sx
- !!emergency decompression of the spinal canal w/n 48 hrs
- nb that nerve root (radiculopathy) causes predominantly sensory Sx
Hx: patient presents with claudication characterised by back and leg pain (aching, heavy, weak) and lower extremity paraesthesia brought on by ambulation and relieved by sitting. Especially bad walking down stairs?
Ex: patient walks with a forward flexed gait
Cause? Ix? Tx? Complications?
spinal stenosis
ΔΔ in facet joint disease (aka facet syndrome) no leg claudication
ΔΔ cauda equina Sx or sciatica Sx
• cause - degeneration (spondylosis), esp facet joints, narrowing of spinal canal, usually lumbar, affects cord AND roots
Ix
• MRI + x-ray
Tx
• NSAIDs, physio, epidural steroid injections, severe: decompressive spinal surgery
• neuro deficit including sensory/motor loss in a quarter
Hx: patient presents with back pain, worse on lying/coughing, rapidly progressing to symmetrical sensory loss, then motor weakness (legs)
+/- ↑reflexes (may be absent if acute)
+/- ↑tone (spastic paraparesis)
+/- sphincter dysfunction (hesitancy, frequency, and later painless retention)
?
spinal cord compression
emergency!
Hx: 45 year old obese patient reports lumbosacral and buttock pain for 1 to 2 days after standing up in a strange position, stiffness, with muscle spasms, otherwise well?
Ex: benign physical examination
Ix? Tx?
mechanical back pain (muscle strain)
Ix - clinical diagnosis, exclude differentials (no X-rays for non-specific lower back pain <6wk)
Tx
• most patients recover within 3 months
• conservative (patient education, return to normal activity, temperature treatments - ice, heat)
• medical (oral NSAIDs, paracetamol, muscle relaxants, opioids if severe)
• physiotherapy if 4-6 weeks
• if chronic (>12 weeks) - CBT, acupuncture, injection therapies
Hx: patent presents with back pain of sudden onset after lifting a heavy object
• which worsens with standing or sitting, or motion, and relieved by rest or lying down
• pain refers to paraspinal muscles, bum, and back of thighs. +/- radicular (dermatomal) pain or in the groin or flank
+/- NO sphincter dysfunction or saddle anaesthesia?
Ex: positive straight-leg raise, pain worse on spine flexion
Ix? Tx?
herniated disc/degenerative disc disease
- lumbar spinal X-ray and MRI
- analgesia, physio, injection or decompression if needed
Hx: patient presents with 6 months history of lumbar back pain, worse with activity, recurrence of previous episode a year previous? Tx?
yellow flags?
chronic back pain
- educate, encourage activity
- pain clinic referral
- optimal analgesia, amitriptyline
- alternative therapies
- physio
- facet joint blocks
- believe activity harmful
- low mood
- sickness behaviour
- work dissatisfaction
- seeking compensation
- not engaged in treatment
Hx: 75 year old lady patient presents with back pain at rest and at night following trauma to back, PMHx distal radius fracture, on long term steroids?
Ex: tenderness to palpation over the midline
• normal neurological ex
osteoporotic compression fracture
Ix • plain x-ray: wedging of the vertebral bodies, typically anteriorly • exclude malignancy or infection! Tx • pain relief • brace • walking aids • surgery if terrible
Hx: patient presents with severe 8/10 back pain, fever, weight loss, pain particularly at rest and at night, on chemo with PMHx DM?
Ex: malaise, fever, local erythema and swelling, localised tenderness (esp on percussion), no neuro Sx
Ix? Tx?
infection (discitis, osteomyelitis)
Ix
• FBC, (↑ neutrophils)
• ESR, CRP
• blood cultures: mostly S. aureus and Strep
• x-rays: may demonstrate end-plate/vertebral body destruction
• MRI: increased signal intensity
Tx
• 4 wks IV Abx
Hx : 56 year old pt presents with back pain at night and at rest, difficulty urinating for 8 months, fevers/chills, weight loss, and malaise +/- neuro Sx?
Ex: local tenderness
Ix? Tx?
malignancy (most commonly 2’ to prostate CA)
Ix
• x-ray, MRI, CT
• chemo, radio, etc
Hx: 30 year old man presents with diffuse non-specific pain over months, goes to buttocks bilaterally, is present at night, worse in the morning with stiffness, fatigue, weight loss?
Pain improves after physical activity.
Ex: stiffness of spine with kyphosis, limited ROM of lower spine, tenderness on palpation, rash (psoriasis) +/- uveitis
Ix? Tx?
ankylosing spondylitis
• “seronegative spondyloarthropathy” - psoriatic arthritis, enteropathic arthritis, and reactive arthritis, HLA-B27 associated
Ix • x-ray: erosion of sacroiliac joint and later narrowing and fusion (bamboo spine) • MRI • FBC (↑wbc) • CRP, ESR • DNA testing: HLA B27 (may be -ve)
Tx
• NSAIDs
• Physiotherapy
• Tumour necrosis factor (TNF-alpha inhibitors)
Hx: 47 year old female patient presents with back pain, knee pain, fever, weight loss, and fatigue?
Ex: rash, signs of malabsorption, joint tenderness, joint effusion and swelling
+/- uveitis, conjunctivitis
+/- lymphadenopathy, wheeze
connective tissue disease (eg, RA)
- FBC
- serum Ab - RF (RA)
- ESR (RA)
- CXR: normal/mediastinal lymphadenopathy/ILD, effision
- plain x-ray of spine:may be evidence of rheumatoid arthritis
Hx: older patient with sudden onset of back pain, and abdo pain, +/- collapse?
Ex: pulsatile abdominal mass, hypotension or hypertension, tachycardia
AAA
Ix
• US/CT if stable
• surgery
Hx: sudden epigastric pain, radiates to back, relieved by sitting forwards, associated with N, V, Hx alcohol or GS?
Ex: tachycardia, fever, jaundice, tenderness/guarding of abdomen, +/- bruising
pancreatitis
- serum lipase
- amylase
- US
- ERCP
Hx: back and flank pain, with dysuria, frequency, and hesitancy, fever, chills, fatigue?
Ex: flank or costovertebral tenderness
pyelonephritis
Ix
• urinalysis, MC+S
• US
Hx: patient has back pain, with severe, acute 10/10 flank pain, may radiate to groin, N, V, on antacids for reflux?
Ex: flank or costovertebral angle tenderness +/- macroscopic haematuria
renal colic
Ix:
• urinalysis
• non-contrast CT
Hx: patient has back pain and epigastric, burning pain, usually after meals, +/- relieved by antacids +/- haematemesis or melaena
Ex: epigastric tenderness, +/- melaena on PR
peptic ulcer disease
Ix:
• upper gastrointestinal endoscopy
which cancers commonly metastasise to the spine?
• prostate (commonest) • breast • lung • kidney (paired organs)
what are the seronegative spondyloarthropathies?
- ank spondylitis (back pain)
- psoriatic arthritis (rash)
- enteropathic arthritis (IBD)
- reactive arthritis (can’t wee, see, climb a tree)
all HLA-B27 associated
