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MBChB YR2 MSK > Disease Profiles: Back Pain > Flashcards

Disease Profiles: Back Pain Flashcards

1
Q

Describe the management of osteoporotic crush fractures

A

Usually conservative, may consider balloon vertebroplasty

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2
Q

Name a genetic condition that predisposes to atraumatic cervical spine instability

A

Down’s syndrome

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3
Q

Describe the examination findings of a patient with sciatica

A

Nerve irritation signs

Motor, sensory, or reflex changes in one nerve root

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4
Q

Describe the examination findings of a patient with vertebral osteomyelitis

A

Paraspinal muscle spasm, spinal tenderness, fever/systemic upset, neurological deficit in severe cases

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5
Q

When is spinal stabilisation surgery indicated for mechanical back pain?

A

Only indicated if a single vertebral level is affected by OA or instability, and the patient has not improved despite physio and conservative management and there are no other adverse secondary gain or behavioural issues which adversely affect outcome of surgery

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6
Q

When would you consider surgery for sciatica?

A

If unremitting/recurrent symptoms

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7
Q

What percentage of patients will be better within 6 weeks of mechanical back pain?

A

90%

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8
Q

Why must you ensure MRI findings correlate with clinical findings before considering surgery for a suspected cervical disc prolapse?

A

The number of patients with asymptomatic disc prolapse increases with age resulting in a higher rate of false positives/incidental findings on MRI scanning

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9
Q

What affect will walking downhill have on a patient with spinal stenosis?

A

Exacerbates symptoms

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10
Q

What investigation would you perform in suspected cauda equina syndrome?

A

Urgent MRI to determine level of prolapse

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11
Q

How would you manage a less severe atlanto-axial subluxation?

A

Collar to prevent flexion

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12
Q

Describe the management of cervical spondylosis

A

Physiotherapy and analgesia

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13
Q

How would you investigate cervical spine instability?

A

X-ray (flexion-extension views)

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14
Q

Why is spinal stabilisation surgery only suitable for a minority of mechanical back pain?

A

Most patients have multi‐level disease of the spine for which there is no role for surgery

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15
Q

Describe the non-surgical management of a patient with vertebral osteomyelitis

A

High dose IV antibiotics appropriate to tissue culture

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16
Q

Describe the usual management of mechanical back pain

A

Lifestyle advice - aim to walk 30 mins a day, stay at work, restrict activity rather than avoid, weight control

Analgesia - NSAIDs first line, weak opiates if needed

Physiotherapy

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17
Q

How would you manage a severe atlanto-axial subluxation?

A

Surgical fusion

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18
Q

What affect will walking uphill have on a patient with spinal stenosis?

A

Relieves symptoms

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19
Q

Describe the management of an acute disc tear

A

Analgesia and physio

Symptoms usually resolve but can take 2-3 months

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20
Q

What causes spondylosis?

A

IV discs lose water content with age, resulting in less cushioning and increased pressure on the facet joint which can lead to secondary OA

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21
Q

Describe the management of vertebral TB

A

As for pulmonary TB

Analgesia

May require surgery - immobilisation of spine region, drainage of spinal abscesses

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22
Q

What causes osteoporotic crush fractures?

A

With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis

Can lead to chronic pain due to altered spinal mechanics

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23
Q

What investigations would you perform in suspected vertebral osteomyelitis?

A

Bloods - raised CRP, blood culture

MRI - extent of infection, abscess formation

CT guided biopsy - tissue culture

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24
Q

Describe the clinical presentation of vertebral TB

A

Slow and insidious back pain, lower limb weakness/paraplegia, kyphotic deformity

1/2 have skin and soft tissue infection, less than 1/2 have pulmonary TB

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25
Q

Describe the clinical presentation of vertebral osteomyelitis

A

Insidious onset of back pain (most commonly lumbar) which is constant and unremitting

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26
Q

Why is back pain from an acute disc tear worse on coughing?

A

Coughing increases disc pressure

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27
Q

What investigation would you perform in a suspected cervical disc prolapse?

A

MRI

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28
Q

What is spondylosis?

A

Spinal osteoarthritis

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29
Q

How can rheumatoid arthritis cause lower cervical subluxations?

A

Destruction of the synovial facet joints and uncovertebral joints

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30
Q

Describe the management of a cervical disc prolapse

A

Conservative - analgesia and therapy

Surgery - consider in cases resistant to conservative management

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31
Q

Describe the clinical presentation of mechanical back pain

A

Pain in lumbosacral region, buttocks and thighs that varies with time and activity

Patient tends to have had several previous ‘flare ups’

No red flags

32
Q

What patient group is most likely to develop mechanical back pain?

A

Age 20-55, obese

33
Q

Why are IV discs more prone to prolapse (herniate) in older patients?

A

As a result of aging the discs become dehydrated and weaken

34
Q

How would you manage a less severe lower cervical subluxation?

A

Conservative - analgesia, physio

35
Q

How would you manage a severe lower cervical subluxation?

A

Consider stabilisation/fusion

36
Q

Describe the clinical presentation of cauda equina syndrome

A

Classically bilateral leg pain (can be unilateral or with no leg symptoms), loss of motor or sensory function of bowel/bladder, saddle anaesthesia, motor weakness in the legs or gait distribution

37
Q

What often causes IV disc herniation?

A

Strenuous physical activity involving the lumbar spine in an older patient

38
Q

Describe the management of cauda equina syndrome

A

Urgent discectomy

39
Q

Describe the clinical presentation of sciatica

A

Unilateral leg pain that is greater than the back pain, sharp, shooting electric pain, pain radiates to foot, numbness and parasthesia in the same distribution

40
Q

Why is new back pain in an older patient (> 60 years) considered a red flag?

A

Higher risk of neoplasia - particularly metastatic disease and multiple myeloma

41
Q

If the C6/7 IV disc prolapses, which nerve root is more likely to be involved?

A

C7

42
Q

What is the most common causative organism for vertebral osteomyelitis?

A

Staph. aureus

43
Q

Describe the management of bony nerve root entrapment

A

Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates

44
Q

Which nerve root is most commonly compressed in sciatica?

A

L5/S1

45
Q

Describe the clinical presentation of spinal stenosis

A

Pain in the legs on walking (claudication), pain is burning in nature

46
Q

What is bony nerve root entrapment?

A

OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica

47
Q

Describe the surgical management of vertebral osteomyelitis

A

Debridement, stabilization and fusion of adjacent vertebrae

48
Q

Describe the conservative management of spinal stenosis

A

Analgesia, physiotherapy, weight loss if indicated

49
Q

What is an acute disc tear?

A

Acute tear in the outer fibrosis of an IV disc which classically happens after lifting a heavy object (e.g. lawnmover)

50
Q

What cardiac condition can cause vertebral osteomyelitis?

A

Endocarditis

51
Q

What is vertebral osteomyelitis?

A

Infection of the vertebrae

52
Q

How would you investigate vertebral TB?

A

X-ray, MRI

Check for immunosuppression/HIV

53
Q

What is spinal stenosis?

A

Narrowing of the central spinal canal, IV foramen and/or lateral recess causing progressive nerve root compression

54
Q

What causes sciatica?

A

Compression of a nerve root, most commonly L5/S1

Usually due to prolapse of a disc which impinges on the nerve root

55
Q

What is mechanical back pain?

A

Recurrent relapsing and remitting back pain with no neurological symptoms

56
Q

What examination would you perform in suspected cauda equina syndrome and what would you expect to see?

A

PR exam - loss of anal sphincter tone

57
Q

How can rheumatoid arthritis cause atlanto-axial subluxation?

A

Destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament

58
Q

What is sciatica?

A

Characteristic pain felt in the lower back, buttocks and the posterior and lower leg that results from compression of any of the 5 nerve roots that contribute to the sciatic nerves

59
Q

Describe the surgical management of spinal stenosis

A

Decompression to increase space for the cauda equina

60
Q

Why is constant, severe back pain worse at night considered a red flag?

A

Suggests tumour or infection rather than mechanical cause

61
Q

Describe the clinical presentation of a cervical disc prolapse

A

Shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected

A large central prolapse can compress the cord leading to a myelopathy with upper motor neurone symptoms and signs

62
Q

Describe the normal management of sciatica

A

90% resolve spontaneously within 3 months - advise NSAIDs and analgesia

63
Q

Describe the clinical presentation of cervical spondylosis

A

Slow onset stiffness and pain in the neck, pain can radiate to shoulders and occiput

64
Q

Name the indications for surgery in vertebral osteomyelitis

A

Inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit

65
Q

What is cauda equina syndrome?

A

A very large central disc prolapse compresses all the nerve roots of the cauda equina

66
Q

What is Pott disease?

A

Vertebral body osteomyelitis and intervertebral discitis from tuberculosis (TB)

67
Q

Describe osteophytes as a complication of cervical spondylosis

A

Osteophytes can impinge on the exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes - may require surgical decompression

68
Q

What causes cervical spondylosis?

A

As with the rest of the spine, spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints

69
Q

Why is back pain from an acute disc tear severe?

A

The periphery of the disc is richly innervated

70
Q

Why is back pain with associated systemic upset (fever, night sweats, weight loss etc.) considered a red flag?

A

May suggest underlying tumour or infection

71
Q

What causes spinal stenosis?

A

Mainly caused by degenerative joint disease in middle aged to elderly individuals - spondylosis, bulging discs, bulging ligamentum flavum and osteophytosis

72
Q

Why is cauda equina syndrome a surgical emergency?

A

Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion

73
Q

What is the most common route of spread for vertebral osteomyelitis?

A

Haematogenous

74
Q

Why is back pain in a younger patient (> 20 years) considered a red flag?

A

Children - more susceptible to infections e.g. osteomyelitis

Adolescents - peak age for spondylolisthesis and some benign and malignant bone tumours

75
Q

When would you consider surgical management of spinal stenosis?

A

If symptoms fail to resolve with conservative management and there is MRI evidence of stenosis

MBChB YR2 MSK (36 decks)

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