Common Musculoskeletal Problems: Back Flashcards
What is the commonest cause of lumbar back in young people and how does it present?
Mechanical, arising from
a. Facet joints
b. Spinal ligaments,
c. Paraspinal muscles
Presentation
- Sudden onset
- Often unilateral
- Improved by rest
Where does mechanical lumbar back pain arise from?
- Facet joints
- Spinal ligaments,
- Paraspinal muscles
Which important patient factor helps in deciding the aetiology of lumbar back pain?
Age - certain causes are more common in particular age groups.
How does mechanical lumbar back pain present?
- Sudden onset
- Unilateral or bilateral
- Usually short-lived - Worse in evening
- Aggravated by exercise or prolonged standing
- Relieved by rest, sitting/lying
- No morning stiffness
- Back stiffness
- Muscular spasm is visible when standing (+/- scoliosis) and palpable with local pain and tenderness
List 5 causes of mechanical back pain
- Lumbar disc prolapse
- Osteoarthritis
- Fractures
- Spondylolisthesis
- Spinal stenosis
How does inflammatory lumbar back pain present?
- Gradual onset
- Worse in morning
- Relieved by exercise
- No morning stiffness
List 2 causes of inflammatory lumbar back pain
- Ankylosing spondylitis
2. Infection
List 5 serious causes of lumbar back pain
- Metastases
- Multiple myeloma
- Tuberculosis osteomyelitis
- Bacterial osteomyelitis
- Spinal or root canal stenosis
List 3 metabolic causes of lumbar back pain
- Osteoporotic spinal fractures
- Osteomalacia
- Paget’s disease
List the red flags for sinister causes of back pain
- Age 50
- Acute onset in elderly
- Constant or progressive pain
- Nocturnal pain
- Morning stiffness
- Worse on being supine
- Thoracic back pain
- Bilateral or alternating leg pain
- Leg claudication or exercise-related weakness/numbness
- Bladder, bowel or sexual function deficit
- Neurological disturbance of >1 root level (incl sciatica)
- Systemic: fever, night sweats, weight loss
- Abdominal mass
- Hx of malignancy, TB
- Current or recent infection
- Immunosuppression (steroids, HIV)
List 3 neoplastic causes of lumbar back pain
- Metastases
- Multiple myeloma
- Primary tumours of bone
List 4 common causes of lumbar back pain in 15-30 year olds
- Mechanical
- Lumbar disc prolapse
- Ankylosing spondylitis
- Spondylolisthesis
List 4 common causes of lumbar back pain in 30-50 year olds
- Mechanical
- Lumbar disc prolapse
- Degenerative joint disease
- Malignancy
List 5 common causes of lumbar back pain in age 50 and over
- Degenerative joint disease
- Osteoporosis
- Paget’s disease
- Malignancy
- Myeloma
List 2 causes of lumbar back pain that affect all age groups equally
- Fractures
2. Infective lesions
True or false: young adults with a history suggestive of mechanical lumbar back pain and with no physical signs require further investigation
False
What are the most important details to note when taking a history of lumbar back pain? (6 in total)
- Age
- Speed of onset
- Neurological symptoms (motor/sensory)
- Bowel/bladder involvement
- Presence of stiffness
- Effect of exercise
What investigations are required when lumbar back pain is likely due to malignancy, infection or a metabolic cause?
- FBC
- ESR
- Serum biochemistry (calcium, phosphate, ALP)
When is it appropriate to obtain blood tests to investigate lumbar back pain?
When you suspect any of the following causes:
- Malignancy
- Infection
- Metabolic
True or false: spinal X-rays are only indicated if there are ‘red flags’ for sinister causes of lumbar back pain
True
True or false: spinal X-rays are always indicated when investigating lumbar back pain
False - only indicated if there are ‘red flags’ for sinister causes
What does bone scintigraphy show?
Increased uptake with
- Infection
- Malignancy
Which conditions of bone is bone scintigraphy not sensitive for?
- Osteoporosis
2. Multiple myeloma
When is MRI indicated for the investigation of lumbar back pain? What does it detect?
When neurological symptoms/signs are present.
Detects disc and cord lesions.
True or false: MRI can demonstrate bone pathology better than CT
False - the opposite is true
True or false: CT can demonstrate bone pathology better than MRI
True
How is mechanical back pain managed?
- Analgesia
- Brief rest
- Physiotherapy
- Should stay active
- exercise programmes reduce long-term problems
What is lumbago?
Low back pain
How does lumbar disc prolapse typically present?
- Sudden onset severe back pain
- Often following a strenuous activity
- Pain is localised and aggravated by movement - Muscle spasm leads to sideways tilt when standing
- May involve radiation to areas supplied by sciatic nerve
True or false: intervertebral disc prolapse is primarily a disease of the elderly.
False - the disc degenerates with age and is no longer capable of prolapse. Disc prolapse is a disease of younger people (20-40 years)
Which discs are most commonly affected by root compression?
Lowest 3 - root lesions at L4, L5, S1
What are the symptoms and signs of S1 root compression?
- Pain: from buttock down back of thigh and leg to ankle and foot
- Sensory loss: sole of foot and posterior calf
- Motor weakness: plantar flexion of ankle and toes
- Reflex lost: ankle jerk
- Diminished straight leg raise
What are the symptoms and signs of L5 root compression?
- Pain: from buttock to lateral aspect of leg and dorsum of foot
- Sensory loss: dorsum of foot an anterolateral aspect of lower leg
- Motor weakness: dorsiflexion of foot and toes
- No reflex lost
- Diminished straight leg raise
What are the symptoms and signs of L4 root compression?
- Pain: lateral aspect of thigh to medial side of calf
- Sensory loss: medial aspect of calf and shin
- Motor weakness: dorsiflexion and inversion of ankle; extension of knee
- Reflex lost: knee jerk
- Positive femoral stretch test
What investigations should be performed for acute disc disease?
Limited value
- X-rays often normal
- MRI only if surgery considered
How would you manage acute disc disease?
- Bed rest - on firm mattress!
- Analgesia
- Epidural steroid injection
- In severe disease - Surgery (microdiscectomy, hemilaminectomy)
a. Severe or prolonged
b. Increasing neurological impairment, e.g. foot drop or bladder symptoms - Physiotherapy
- Correct posture
- Restore movement
When might surgery be considered for acute disc disease?
- Severe pain
- Increasing neurological impairment - foot drop, bladder symptoms
Ix: MRI beforehand
How does chronic compare to acute disc disease?
- Pain due to degenerative changes in lumbar disc and facet joints
- Also of mechanical type
- +/- sciatic radiation to buttocks, thigh - Long-standing
- Limited Rx:
- NSAIDs
- Physio
- Weight reduction - Surgery:
- If arising from single identifiable level and failed to respond to conservative measures
- Fusion with decompression of affected nerve roots
What is spondylolisthesis and at which level does it most commonly occur?
A slipping forward of one vertebra on another due to defect in pars interarticularis.
- Commonly L4/L5
- Congenital or acquired
Which condition may arise due to a defect in the pars interarticularis?
Sponylolisthesis
How does spondylolisthesis typically present?
- Mechanical pain - worsens throughout day
- Pain may radiate to either leg
- Signs of nerve root irritation
How would you manage spondylolisthesis?
Depends on size: Small - Associated with degenerative disease - Conservative: simple analgesics Large - Severe symptoms - Operative: spinal fusion
What is the main complication of spinal stenosis and what key symptoms is it associated with?
Cord compression:
- Buttock and bilateral leg pain
- ‘Heaviness’
- ‘Spinal claudication’: pain/paraesthesiae/numbness triggered after period of walking, easing with rest or leaning forwards
How does cauda equina compression present?
- Back and buttock pain
2. ‘Spinal claudication’: pain triggered after period of walking, easing with rest
List 4 causes of spinal stenosis
- Disc prolapse
- Degenerative osteophyte formation
- Tumour
- Congenital narrowing of spinal canal
Which investigations are indicated for cord compression?
CT and MRI
How is spinal stenosis with cord compression treated?
Surgical decompression
- Laminectomy
As well as the lumbar spine, disc disease may also occur in…?
Cervical spine
- 3 lowest discs most commonly
How does cervical disc disease present?
- Pain
- Stiffness
- +/- Root pain radiating to arm
What is cervical spondylosis?
Chronic disc disease of the cervical spine
An 55 year old patient presents with a two month history of lumbago. You perform some blood tests. ESR and CRP are raised. What is the most likely differential diagnosis?
Polymyalgia rheumatica
Normal ESR and CRP distinguish mechanical back pain from PMR, a likely differential in the elderly.
What are the 3 main risk factors for recurrent back pain?
- Female sex
- Pre-existing fibromyalgia
- Psychological factors
- Stress
- Poor self-rated health
- Employment dissatisfaction
A patient complains of lumbar back pain. Which 5 conditions may give rise to the appearance of spondylosis on X-ray?
- Postural back pain
- Lumbar spondylosis
- Facet joint syndrome
- Fibrositic nodulosis
- Sway back of pregnancy
How do age-related changes of the intervertebral discs appear on MRI?
Decreased hydration
- Thinning
- Circumferential bulging of intervertebral ligaments
Reactive changes in adjacent vertebrae
- Sclerotic changes
- Osteophytic formation around rim
What are Schmorl’s nodes?
Disc prolapse through adjacent vertebra in young people - best seen with X-rays
What are the complications of spondylosis? (6 in total)
Can be asymptomatic. 1. Episodic mechanical back pain 2. Progressive spinal stiffness 3. Facet joint pain 4. Acute disc prolapse \+/- nerve root compression 5. Spinal stenosis 6. Spondylolisthesis
What is facet joint syndrome?
OA secondary to lumbar spondylosis, causing misalignment of facet joints
- Pain on full extension or straightening from flexion
- Unilateral/bilateral, lumbar
- Radiation to buttocks, leg(s)
What is the imaging of choice for facet joint syndrome?
MRI
- OA
- Effusion
- Ganglion cysts
How is facet joint syndrome treated?
- Steroid injection under imaging
- Physiotherapy
- Weight reduction
What is fibrositic nodulosis?
Tender nodules in upper buttock and along iliac crest - probably traumatic
What type of back pain are pregnant women predisposed to?
Sway back of pregnancy
- Hyperlordosis
- Increased ligament laxity
How do you differentiate spinal from arterial claudication?
Presence of normal foot pulses
Name 2 neurosurgical emergencies and differentiate between them
- Acute caudal equina compression
- Alternating or bilateral leg pain
- Saddle anaesthesia
- Loss of anal tone on PR
- Bladder and bowel incontinence - Acute cord compression
- Bilateral leg pain
- LMN signs at level of compression
- UMN signs and sensory loss below level of compression
- Sphincter disturbance
True or false: acute cord compression is associated with UMN signs at level of compression and LMN signs and sensory loss below level of compression.
False - opposite
True or false: acute cord compression is associated with saddle anaesthesia
False - acute caudal equina compression
True or false: acute cord compression associated with alternating or bilateral leg pain
False - only bilateral (caudal equina compression is associated with alternating)
List 6 causes of acute neurosurgical emergencies
- Bony metastasis
- Lack of pedicle on X-ray - Large disc protrusion
- Myeloma
- Cord or paraspinal tumour
- TB
- Abscess
Which condition is thoracic or lumbar crush fracture of the spine most commonly associated with?
Osteoporosis
What is a ‘widow’s stoop’?
Increased thoracic kyphosis associated with elderly women due to multiple osteoporotic crush fractures
How does osteoporotic crush fracture appear on imaging and what conditions need to be excluded?
X-ray:
1. Loss of anterior vertebral body height and wedging
2. Sparing of vertebral endplates and pedicles
MRI:
- Effusion indicates recent #
Exclude
- Tumour
- Pathological fracture
How would you manage an osteoporotic crush fracture?
- Bone density measurement
- Osteoporosis prevention
Conservative:
- Bed rest
- Analgesia
- IV Bisphosphonates and SC calcitonin relieve pain
Operative:
- Percutaneous vertebroplasty
- Balloon kyphoplasty
- Insert needle through vertebral body and inject with cement alone or balloon-filled with cement
