🩻MSK🩻 - Back Pain Flashcards
What are the functions of the spine?
Locomotor - capable of being both rigid and mobile
Bony armour - protects the spinal cord
Neurological - spinal cord transmission of signals between brain and periphery
What is the spinal column made up of?
24 Vertebrae
-7 cervical
-12 thoracic
-5 lumbar
Intervertebral discs
Facet joints – small synovial joints at posterior spinal column linking each vertebra
Muscles – move the spine
What are the key neurological structures of the spine?
Spinal cord - transmission of signals to/from brain. Ends at L2 vertebra
Nerve roots - exit spinal cord bilaterally
Cauda equina - nerve bundle
Where is a lumbar puncture performed and why?
L3/L4 space to avoid spinal cord which ends at L2
Describe the movements of the spine
Outline back pain
Very common: >50% of people will experience an episode
Acute back pain usually self-limiting
Most better in a few days, 96% are better in six weeks
Chronic back pain (>12 weeks duration) also common – sedentary lifestyle
Need to distinguish mechanical back pain from serious pathology
What is mechanical back pain?
Reproduced or worse with movement
Better or not present at rest
What are the most common causes of mechanical back pain?
Muscular tension (e.g. chronic poor posture, weak muscles)
Acute muscle sprain/spasm
Degenerative disc disease
Osteoarthritis of facet joints
What is sciatica?
Pain radiating down a leg
How does sciatica tend to arise?
Disc herniation (“slipped disc”) contacting the exiting lumbar nerve root
What are the serious pathological causes of back pain?
Tumour - metastatic cancer or myeloma
Infection - Discitis, Vertebral osteomyelitis, Paraspinal abcess, Microbiology: Staphylococcus, streptococcus, tuberculosis (TB)
Inflammatory spondyloarthropathy
Fracture (traumatic or atraumatic)
Large disc prolapse causing neurological compromise
Referred pain
What are inflammatory spondyloarthropathies?
Group of immune-mediated inflammatory diseases
Ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD)
Primarily inflammation of the spine (spondylitis) and sacro-iliac joints (sacro-iliitis)
Peripheral joints, esp. tendon insertions (entheses), can also be affected
What are the extra-articular manifestations of Inflammatory Spondyloarthritis (SpA)?
Anterior uveitis (iritis) – ocular inflammation
Apical lung fibrosis
Aortitis/aortic regurgitation
Amyloidosis – due to chronically raised serum amyloid A (SAA) depositing in organs
What is meant by “referred pain” in the context of serious back pain pathologies?
Pain referred from more serious conditions, such as pancreatic disease/cancer, kindey disease/injury/cancer and aortic aneurysms
What are the “red flag” symptoms in back pain?
Pain at night or increased pain when supine
Constant or progressive pain
Thoracic pain
Weight loss
Previous malignancy
Fever/night sweats
Immunosuppressed
Bladder or bowel disturbance (Sphincter dysfunction)
Leg weakness or sensory loss
Age <20 or >55 yrs
What is cauda equina syndrome?
Nerves at the base of the spinal cord (cauda equina) are compressed
Neurosurgical emergency
Untreated = permanent lower limb paralysis and incontinence
What are the symptoms and signs of cauda equina syndrome?
Saddle anaesthesia
Bladder/bowel incontinence
Loss of anal tone
Radicular (bilateral shooting) leg pain
Ankle jerks may be present
What is the investigation for suspected cauda equina syndrome?
Urgent MRI L spine
What are some of the causes of cauda euina syndrome?
Large disc herniation
Bony mets
Myeloma
TB
Paraspinal abscess
What is the treatment for cauda equina syndrome?
According to cause - often urgent surgery
What should be asked when taking a history of back pain?
Site/pattern
Onset
Character (aching, throbbing, burning, electric)
Radiation (e.g. sciatica)
Associated symptoms (morning stiffness, buttock pain, leg weakness, paraesthesia/numbness)
Time
Exacerbating/relieving factors (effect of movement vs inactivity)
Severity
How is the spine examined?
Look
Feel
Move
Straight leg raise (SLR)
Lower limb neurological exam
General exam (signs of malignancy, AAA)
What is the guidance for investigation of back pain?
In the absence of red flags, investigation usually not required
Arrange review if symptoms persist or worsen after 3–4 weeks and reassess for an underlying cause
What is the treatment for lower back pain without any red flags?
What are the blood investigations for back pain?
ESR
CRP
FVC
Alkaline phosphatase (ALP)
Calcium
PSA
What would an abnormal ESR indicate?
Myeloma, chronic inflammation, TB
What would an abnormal CRP indicate?
Infection or inflammation
What would an abnormal FBC indicate?
Anaemia in myeloma, chronic disease, increased WCC in infection
What would an abnormal ALP indicate?
Bony mets
What would an increased calcium indicate?
Could indicate myeloma or bony mets
What would an abnormal PSA indicate?
Bony mets originating from prostate cancer
What are the options for imaging of back pain?
Radiographs (X-rays)
CT scans
MRI
Pros/cons X-rays for back pain
Poor sensitivity, radiation
Cheap, widely available
Pros/cons CT
Good for bony pathology
Larger radiation dose
Pros/cons MRI
Best visualization of soft tissue structures like tendons and ligaments
Best for spinal imaging: can see spinal cord and exiting nerve roots
Expensive and time-consuming
What are the key points about diagnostic imaging in low back pain
Radiographs have negligible value in assessment of back pain
CT is an adjunct in a few cases
MRI is main modality
Low back pain is non-specific until further investigated
70 year old woman
Acute onset thoracic spine pain with radiation through to the chest wall
Focally tender over thoracic spine
Does she need investigation?
Thoracic pain, elderly is red flag
Acute onset is odd
What does this x-ray show?
25 year old man originally from Nepal
Worsening low back pain for 8 weeks
Worse in the morning but present at all times
Weight loss
Night sweats
Does he need investigation?
Differential diagnosis?
Weight loss night sweats –infection-tb?
Could be cancer, less likely in 25yrold-lymphoma in young ppl?
morning stiffness - characteristic of ankylosing spondylitis
What does this show?
T1: L4/5 endplate destruction. Soft tissue mass encroaching spinal canal
T2: altered signal in sacral segments
Have spinal tb with paraspinal absess- eating away at disc and spine
A 45-year-old man complains of acute back pain and sciatica extending down the R leg into the foot associated with paresthesia
No incontinence of bladder/bowel
Examination: no weakness, sensation intact
He has been off work for two weeks and wants to know when he can get back to work
Does he need imaging?
Likely diagnosis?
Doesnt need imaging cos no red flags
Mechanical back pain with sciatica-slipped disc-touching nerve root –shooting pain
Outline the natural history and treatment for herniated discs
Most prevalent in individuals aged 30-50
Good outlook
Normally spontaneous improvement, although typically slower than for low back pain alone
Treatment:
1. Conservative as for LBP without sciatica
-Analgesia especially NSAIDs
-Physiotherapy to improve core strength and treat associated muscle spasm
2. Nerve root injection (local anaesthetic and glucocorticoid)
3. Surgery if neurological compromise or symptoms persist
25 year old woman
Presents with 1 year history of lumbar and buttock pain, with morning stiffness lasting 2 hours
Ibuprofen helps
Examination: reduced range of L spine movements
Does she need imaging?
Likely diagnosis?
Prolonged morning stiffness is red flag- so need imaging so ankylosing spondylitis
Briefly outline the pathophysiology of ankylosing spondylitis
Ankylosing spondylitis (AS) is a disease linked to inflammation where tendons and ligaments attach to bones (enthesitis). It has a strong genetic component, particularly the HLA-B27 gene, which is found in most AS patients but not everyone with HLA-B27 develops the disease. Key immune factors like TNF-alpha, IL-17, and IL-23 contribute to its development.
No need to know background for exam just need to know HLA is a marker for ankyjwnbf spodhuewhf
How is ankylosing spondylitis managed?
Physiotherapy and a life-long regular exercise programme
Pharmacological
1st line: non-steroidal anti-inflammatory drugs (NSAIDs)
-e.g. ibuprofen, naproxen, diclofenac
2nd line: ‘Biological’ therapies
Therapeutic monoclonal antibodies (mAbs) targeting specific molecules
