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Week 11- Musculoskeletal > Back pain and spinal disorders > Flashcards

Back pain and spinal disorders Flashcards

1
Q

What is the definition of chronic back pain?

A

Back pain lasting at least 3 months

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2
Q

What are the broad causes of back pain?

A
  • Mechanical (97%)
  • Referred
  • Systemic
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3
Q

Describe non specific lower back pain

A
  • Onset at any age with a variable rate
  • Generally worsens with movement or prolonged standing
  • Gets better with rest
  • Early morning stiffness <30 minutes
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4
Q

What are the causes of non specific lower back pain?

A
  • Lumbar strain/sprain
  • Degenerative discs/facet joints
  • Disc prolapse, spinal stenosis
  • Compression fractures
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5
Q

What is the most common cause of mechanical back pain?

A

Lumbar strain/sprain

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6
Q

Describe pain in degenerative disc disease (Spondylitis)

A
  • For many it is an asymptomatic disc disease

* Pain increases with flexion, sitting, sneezing

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7
Q

Describe pain in degenerative facet joint disease

A
  • more localised

* Increased with extension

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8
Q

What is the management of non specific lower back pain?

A
  • Keep the diagnosis under review
  • Reassure patient (majority settles within 3 months of symptom onset)
  • Education, promote self management
  • Exercise programme and physiotherapy
  • Analgesics as appropriate but avoid opiates
  • Acupuncture
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9
Q

What should be avoided in the management of non specific lower back pain?

A
  • Injections
  • Traction
  • Lumbar supports
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10
Q

What determines the symptoms experienced in patients with a disc herniation?

A

Which nerve it is compressing

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11
Q

Where do discs herniate?

A

Straight back compressing the spinal cord or to the side compressing the nerve root

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12
Q

What is a radiculopathy

A

The symptoms that occur when a nerve is pinched/compressed

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13
Q

Describe the signs of a disc prolapse/herniated nucleus pulposus

A
  • May be acute
  • Typically leg pain over back pain (sciatica)
  • Straight leg raising test will be positive
  • Reduced reflexes
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14
Q

Describe the management of a disc prolapse

A
  • Most resolve spontaneously within 12 weeks
  • Wait with investigations i.e. MRI and only do if it is not settling
  • 10% will need surgery but this tends to help the leg pain and not the back, there is no clear benefit of surgery at 1 year
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15
Q

What cause of back pain warrants an urgent neurosurgical review?

A

Cauda equina syndrome

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16
Q

What level does the spinal cord end?

A

L1/2

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17
Q

What are the symptoms of cauda equine syndrome?

A
  • neuropathic symptoms: bilateral sciatica, saddle anaesthesia
  • Bladder or bowel dysfunction: reduced anal tone
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18
Q

What is the usual cause of cauda equina syndrome?

A

A large prolapsed disc

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19
Q

What is spinal stenosis?

A

Anatomical narrowing of the spinal canal - can be congenital and/or degenerative

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20
Q

What is the presentation of spinal stenosis?

A
  • Often presents with claudication in the legs/calves, worse when walking
  • Normally both legs, if just one, think vascular
  • Natural history is variable
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21
Q

What investigations should be carried out in suspected spinal stenosis?

A

X ray and MRI but only if the diagnosis is uncertain or imaging will alter management

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22
Q

What is spondylolisthesis?

A

Slip of one of the vertebra on the one below

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23
Q

Describe pain in spondylisthesis?

A
  • May radiate to the posterior thigh

* Increases with extension

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24
Q

Where may there be a defect in someone with spondylolisthesis?

A

Pars interarticularis

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25
Q

Describe pain in a compression fracture

A
  • Often sudden onset and severe
  • Radiates in a belt around the chest/abdomen
  • Most pain settles in 3 months
26
Q

What is a compression fracture associated with?

A
  • Old age

* Osteoporosis

27
Q

What investigations can be carried out for a compression fracture?

A
  • X ray

* DEXA (bone density scan)

28
Q

What is the treatment for a compression fracture?

A
  • Conservative (analgesia)
  • Calcitonin
  • Vertebroplasty (cement) or kyphoplasty (balloon)
29
Q

What can present as referred back pain?

A
  • Aortic aneurysm
  • Acute pancreatitis
  • Peptic ulcer disease (duodenal)
  • Acute pyelonephritis
  • Endometriosis/gynae
30
Q

What are the symptoms of aortic aneurysm?

A
  • CVS features (BP and tachycardia)
  • pulsating abdo mass
  • Collapse
31
Q

What are the symptoms of acute pancreatitis?

A
  • Epigastric pain
  • Relief on leaning forwards
  • Systemically unwell
32
Q

What are the symptoms of peptic ulcer disease?

A
  • Epigastric pain, especially after meals
  • history of peptic ulcer disease
  • Vomiting blood
  • malaena
33
Q

What are the symptoms of acute pyelonephritis

A
  • History of UTI/stones
  • Unwell
  • Haematuria
  • Frequency
34
Q

What are the systemic causes of back pain?

A
  • Infection: discitis, osteomyelitis, epidural abscess
  • Malignancy
  • Inflammatory
35
Q

What are the symptoms of infective discitis?

A
  • Fever (May be a pyrexia of unknown origin)
  • Weight loss
  • Constant back pain, on rest and at night
36
Q

What is a typical PMH of someone presenting with infective discitis?

A
  • Immunosuppressed
  • Diabetes
  • IV drug user
37
Q

What investigations should you carry out in suspected infective discitis?

A
  • FBC, ESR, CRP
  • blood cultures
  • Imaging: X ray/ MRI (x ray can be normal at beginning)
  • Radiology guided aspiration
38
Q

What is the most common cause of infective discitis?

A

Staph aureus

39
Q

What is the treatment of infective discitis?

A

IV antibiotics +/- surgical debridement

40
Q

What is the appearance of infective discitis on Xray?

A
  • can’t see the disc space (can heal with complete loss of the disc space)
  • Changes on both sides of the vertebrae
41
Q

Which cancers are most likely to metastasise to the spine?

A
  • Lung
  • Prostate
  • Thyroid
  • Kidney
  • Breast
42
Q

What are the symptoms of malignancy in the spine?

A
  • Constant pain, often worse at night

* Systemic symptoms, primary tumour signs and symptoms

43
Q

Describe malignancy in the spine on xray

A

Margin tends to be normal on one side and abnormal on the other

44
Q

Describe the symptoms of inflammatory back pain

A
  • Early morning stiffness lasting >30 mins
  • Back tends to be stiff after rest and improves with movement
  • may wake in the 2nd half of the night with buttock pain
45
Q

What is the rule of 10s?

A
  • Of all patents with chronic lower back pain, 10% will have inflammatory symptoms
  • 1% will have Ankylosing spondylitis or axial spondyloarthritis
46
Q

What are the red flag signs when someone is presenting with back pain?

A
  • 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 immunocompromised
  • Recent significant infection
  • Urinary retention
  • Non mechanical pain or pain worse at night
  • Thoracic spine pain
  • Signs: saddle anaesthesia, reduced anal tone, hip or knee weakness, generalised neurological defect, progressive spinal deformity
47
Q

What are the types of inflammatory back pain?

A
  • Ankylosing spondylitis
  • non-radiographic axSpA
  • Other
48
Q

What are the predictors of progression of axSpA

A
  • Smoking
  • Existing damage
  • Male
49
Q

What is the common presentation of an inflammatory back pain?

A
  • Onset less than 45 years old
  • Early morning stiffness >30mins
  • Back stiff after rest and improves with movement
  • may wake in the second half of the night
  • Buttock pain
50
Q

What are the spondyloarthritis features?

A
  • Inflammatory back pain
  • Arthritis
  • Enthesitis (heel)
  • Uveitis
  • Dactylitis
  • Psoriasis
  • Chrons/colitis
  • Good response to NSAIDs
  • Family history for SpA
  • HLA-B27
  • Elevated CRP
51
Q

What is the ASAS classification criteria for axial SpA?

A

In patients with a >/3 month history of back pain and age at onset less than 45 years:
•Sacroilitiis on imaging with at least one SpA feature
OR
•HLA-B27 with at least 2 SpA features

52
Q

What is the difference between classification and diagnostic criteria?

A
  • In classification criteria the diagnosis is already known and you do not have to exclude other potential causes
  • Diagnostic criteria the diagnosis is not yet known and you require the exclusion of other potential causes for symptoms/results
53
Q

What are the symptoms of axial spondyloarthritis?

A 
•Inflammatory back pain 
•Fatigue 
•Arthritis in other joints: knees, hips 
•Enthesitis: Achilles tendon, plantar fasciitis 
•Inflammation outside joints: 
 - eye= uveitis 
 - skin: psoriasis 
 - Bowel: churns disease/UC
 - Other: heart, lungs, osteoporosis 
•Family history of above
54
Q

What is the recommended imaging for axSpA?

A
  • Pelvic AP Xray
  • Lumbar spine X ray
  • MRI allows for the earlier identification of macro-ilitis
55
Q

Describe the appearance of the lumbar spine on X ray in ankylosing spondylitis

A
  • Sclerosis - shiny corners of vertebrae
  • Syndesmophytes and spondylophytes (look like notches on the anterior aspect of the spine)
  • Bridging syndesmophytes
56
Q

What are the mimics of ankylosing spondylitis on MRI?

A
  • Infective sacro-iliits

* Insufficiency fracture

57
Q

Give an overview of the process of diagnosing ankylosing spondylitis and

A
  • Someone comes in with features suggestive of a diagnosis
  • Imaging supports this
  • Look for associated features: family history and extra articular features
  • Other investigations: HLA-B27 status and CRP/ESR
58
Q

Why do people get axSpA and AS?

A
  • Genetic susceptibility: HLA-B27 positive, IL-23R, Th17 response
  • Environment: infection and microbiome in the gut/on the skin
  • Biomechanics
59
Q

Explain the IL-23 and IL-17 pathway in enthesitis and axSpA

A
  • Gut microbiome, HLA-B27 and biomechnaical stress cause an increase in the production of IL-23
  • IL-23 causes T cell to release cytokines and causes the increase of IL-22 and IL-17
  • IL-22 causes osteoproliferation and IL-17 causes bone loss, both IL-22 and IL-17 cause inflammation
  • This combined effect results in ankylosis
60
Q

what can patients with ankylosing spondylitis and axial spondyloarthritis do to help themselves?

A
  • Exercises
  • Stop smoking
  • Self management strategies
  • healthy diet and sleep
61
Q

What are the treatment options for axSpA?

A
  • NSAIDS
  • Analgesics
  • Surgery
  • Biologic drugs: TNF inhibitors and IL-17A inhibitors

Week 11- Musculoskeletal (11 decks)

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