LBP, Neck Pain + Osteoporosis Flashcards
Serious causes of LBP to be r/o
Cauda Equina
Pyelonephritis
AAA rupture
Cancer
Signs of AAA
pulsatile mass, pain, hypotension
Causes of neck pain
Lymphoma
Carotid dissection
Referred pain: MI, pseudotumour cerebri
Nerve/ spinal cord compression
Muscular neck pain
Degenerative disc disease
What are the C spine rules for XR?
Any high risk features?
Age ≥65yr or
Dangerous mechanism* or
Paresthesias in extremities
If yes - XR
If no:
Any low risk features?
Simple rear-end MVC** or
Sitting position in ED or
Ambulatory at any time or
Delayed onset of neck pain*** or
Absence of midline cervical spine tenderness
If no - XR
If yes:
Is pt able to actively rotate neck left and right 45 degrees?
Yes: cleared
No: XR
What are the dangerous mechanisms for C spine injury?
Fall from elevation ≥91.5cm/5 stairs
* Axial load to head, eg diving
* MVC high speed (>100km/h),
rollover, ejection
* Motorised recreational vehicles
* Bicycle crash
Dx of OP
Fragility # hip or spine
Low BMD (<-2.5)
High FRAX score + T score <-1
Fragility # + T score <-1
definition of Fragility fracture
after age 40: spontaneous # or # from minor trauma
Primary prevention of OP
Calcium
Physical activity - strength, balance + aerobics
Smoking cessation
Hip protectors
Advise on fracture prevention
Physical fitness
Reduce alcohol
Smoking cessation
Risk of physical abuse
Environmental factors contributing to falls
Meds contributing to falls
Reasons to screen for osteoporosis
Age over 65
Age over 40 + Fragility Fracture
Prolonged Glucocorticoids (>3months)
Family History of Hip Fractures
Presence of Vertebral Fracture
Evidence of Osteopenia on X-Ray
Smoking
EtOH Intake
Early Menopause (age <45)
Rheumatoid Arthritis
Primary Hyperparathyroidism
Hypogonadism
Low Body Weight (<60kg)
Major Weight Loss (>10% loss at age 25)
Malabsorption Syndrome
T scores for osteopenia + osteoporosis
Osteopenia: -1.0 to -2.5 SD
Osteoporosis: -2.5 or less
Indication for BMD in
<50
Fragility #
Prolonged steroid use
High risk med (aromatase inhibitors, androgen deprivation therapy)
Hypogonadism
Premature menopause
Malabsorption syndrome
Primary hyperparathyroidism
Indication for BMD in >50
Age >65
Fragility # >40 y/o
Prolonged steroids
Parental hip #
Smoker
High alcohol intake
Wt <60kg
RA
High risk med (aromatase inhibitors, androgen deprivation therapy)
Ix after Dx of OP
Calcium corrected with albumin
CBC
Cr
ALP
TSH
SPEP if vertebral #
Secondary causes of OP
Endo: acromegaly, DM, hyperparathyroidism, hyperthyroidism, hypogonadism, low phosphate, porphyria, pregnancy
GI: alcoholism, anorexia, liver dz, malabsorption
Drugs: anti-epileptics, aromatase inhibitors, immunosuppressants, lithium, PPI, SSRI
Other: COPD, HIV, AS, hemophilia, MDD, myeloma, CKD, RA
Management - 10 yr # risk <10%
<10%:
Lifestyle
Calcium/Vitamin D
Repeat BMD in 5 years
Management - 10 yr # risk 10-20%
Lifestyle
Calcium/Vitamin D
Lateral thoracolumbar XR (T4-L4)
If RF present, start meds. No RF, repeat BMD in 1-3yrs.
RF:
additional vertebral #s
prev wrist #
lumbar spine T score «_space;femoral neck T score
Rapid bone loss
Androgen deprivation therapy for prostate cancer
Longterm steroids
Recurrent falls
Management - 10 yr # risk >20%:
Lifestyle
Calcium/Vitamin D
Women: bisphosphonate, denosumab if v high risk
Men: alendronate, zoledronic acid
Bisphosphonates
Alendronate 70mg weekly or risedronate 35mg weekly
SE, how to mitigate + “drug holiday” of bisphosphonates
Drug holiday after 10 yrs
SE: Esophagitis, Dyspepsia, Nausea
Bisphosphonates advice: take sitting up, half hour before meals, empty stomach, plenty of water
What rule to use in <16 y/o for ?C spine fracture + what are the components
NEXUS
C spine not necessary if they have an Alert MIND:
Alert
No midline tenderness
No intoxication
No neuro deficit
No distracting injury
Types of unstable cervical fractures
Jefferson’s fracture (C1 compression), Hangman’s fracture (C2 bilat pars), bilateral cervical facet dislocation, odontoid, atlanto-occipital dissociation
Red flags in neck pain
ripping/ tearing sensation, concurrent CP, wt loss, immunosuppression, IVDU, neuro deficit, vision changes, hx of malignancy
What is the safety issue with neck pain?
Driving
Neck pain in RA = what?
atlanto axial disruption
Who is not eligible for bisphosphonate drug holiday
vertebral + hip fractures
FRAX score components
WASH F SCRAPS
wt
age
sex
ht
femoral neck bmd
steroids
current smoking
RA
alcohol >3/d
parent hip frac/ prev frac
secondary OP
When to start bisphosphonate?
If FRAX score >20% or confirmed OP
OP dx clinically (not using BMD)
take height yearly, if loss of height by 2cm prospective or 6cm historical, look for vertebral fractures - fractures = OP
When to order BMD
if at risk or had fracture
What labs to order w/ vertebral fractures?
Hb, TSH, ionized Ca, Alk Phos, Cr, SPEP, vit D
How much Ca + Vit D to advise people to have?
1000mg calcium, 1000U Vit D
SE bisphosphonates
esophageal ulcer, increased atypical fractures, jaw osteonecrosis
Class + SE of raloxifene
selective estrogen receptor modulator. VTE + PE
What to use for high risk OP pts?
Denosumab (monoclonal ab)
SE denosumab
joint pain, jaw osteonecrosis
Drug holidays in OP
drug holiday for 5 yrs after been on drug for 5 yrs, except high risk pts
RED-S - what is it?
relative energy deficiency in sport
low caloric intake, +/- disordered eating, amenorrhea, low BMD
Rx for OP
bisphosphonates, raloxifene (selective estrogen receptor modulator) + teriparatide (PTH analog), denosumab (MAB)
