Back pain and Arthritis

Question 1

How do you carry out a straight leg test? What does a positive test mean?

Answer 1

Raise a patients leg whilst they are supine with their knee extended. A positive test would be if the patient experiences pain below the knee which increases on dorsiflexion.

A positive test indicates irritation to the sciatic nerve.

Question 2

What is a femoral stretch test

Answer 2

Lie the patient prone and extend the hip with the patients knee flexed

Question 3

At what age range would you expect to see a patient with a prolapsed disc?

Answer 3

15-50 years old

Question 4

At what age would you expect to see a patient with ankylosing spondylitis?

Answer 4

15-30 years old

Question 5

What type of cancers are most likely to metastasise to bone?

Answer 5

Thyroid

Lung

Breast

Kidneys

Prostate

Question 6

What pain management would you prescribe for a patient with back pain?

Answer 6

Simple analgesics/mild opiates initially - Paracetamol/NSAID’s/Codeine

If these fail then consider low dose amitryptilline/duloxetine

Question 7

What X-ray changes would you expect to see in an osteoarthritic joint?

Answer 7

L - Loss of joint space

O - Osteophytes

S - Subchondral sclerosis

S - Subchondral cysts

Question 8

What is the conservative management for OA?

Answer 8

Weight loss if required

Analgesia

Exercise to stregnthen/build the muscles surrounding the joint

Question 9

Name some risk factors for septic arthritis?

Answer 9

Pre-existing joint disease

Diabetes mellitus

Immunosuppression

Chronic renal failure

IVDU

Recent joint surgery/prosthesis

Question 10

What investigations would you order in a patient with suspected septic arthritis?

Answer 10

Urgent joint aspiration for urgent MC&S

Blood culture

Commence the sepsis 6 straight away!

Question 11

What are the common causative organisms of septic arthritis?

Answer 11

Staphylococcus aureus

Streptococci

Neisseria gonococcus

Gram negative bacilli

Question 12

How long is an antibiotic regimen needed for a patient with septic arthritis?

Answer 12

2 weeks IV and 2-4 weeks PO following this (only switch to PO if the patient has shown improvements/recovery of the affected joint)

Question 13

Side effects to consider when prescribing NSAID’s?

Answer 13

“IGRAB”

I - interactions with other medication

G - Gastric ulceration

R - Renal impairment

A - Asthma sensitivity

B - bleeding disorders (due to effects on the platelet action)

Question 14

What HLA’s are linked to rheumatoid arthritis?

Answer 14

HLADR1 and HLADR4

Question 15

How does Rheumatoid usually present?

Answer 15

Symmetrical swollen painful joints

Stiff joints of the hands and feet that is worse in the mornings

Question 16

What treatment regimen achieves the best results in RA?

Answer 16

MTX + Sulfasalazine + Hydroxychloroquine

Question 17

Side effects of methotrexate?

Answer 17

Hepatotoxicity

Apthous ulcers

Pneumonitis

Teratogenicity

Question 18

What are the side effects of sulfasalazine?

Answer 18

Apthous ulcers

Rash

Decreased sperm count

Question 19

What test need to be run before commencing anti-TNF alpha treatment?

Answer 19

TB testing

HIV testing

HepB/C testing

Ensure that the patient does not have an underlying malignancy

Question 20

What are the red flags for back pain?

Answer 20

<20 or >50y/o

Acute onset in elderly people

Constant or progressive pain

Nocturnal pain - indicates inflammatory

Worse pain on being supine

Fever night sweats and weight loss

Hx of malignancy

Abdominal mass

Thoracic back pain

Morning stiffness

Bilateral or alternating leg pain - cauda equina

Neurological disturbance

Sphincter disturbance

Current or recent infection

Immunosuppression

Leg claudication or exercise related weakness/numbness (indicating spinal stenosis)