MSK Hx's Flashcards
What are the components of HPC for back pain?
- O’SOCRATES
- open q, site, onset, character, radiation, associated features, timing, exac/releiving factors & severity
- Associated symptoms
- Cord compression
- waterworks/bowel/weakness/strange sensations down legs/buttocks
- in men: difficulty gaining erections?
- inflammatory
- stiff back in the morning & if yes how long lasting?
- constitutional
- any sig weight loss over the past few months? Appetite? fever/ill? mood?
- ICE
- what do you think is wrong? whats your biggest concern?
- Cord compression
What conditions should be asked about specifically in back pain Hx for PMH and FH?
- PMH
- osteoporosis, arthritis, TB and previous cancer
- FH
- ankylosing spondylitis and osteoporosis
What are the red flag symptoms in back pain Hx?
- red flag symptoms = indicative of serious pathology
- TUNA FISH
- trauma, unexplained weight loss, neurologic symptoms, age >50, fever, IVDU, Steroid Use, History of cancer (prostate, renal, breast, lung)
- cord compression and cauda equina are medical emergencies that should be sought after in the Hx
- progressively worsening pain not relieved by rest
- age of onset under 20 or over 50 yrs
- urinary/foecal incontinence, leg weakness, saddle anaethesia
- hx of cancer; weight loss; fever
- sever trauma or minor trauma in presence of known osteoporosis
What are the yellow flag symptoms to watch for in back pain Hx?
- yellow-flag symptoms are prognostic of long term disability:
- negative attitude that their back pain is severely disabling
- belief that activity is harmful to recovery
- belief that passive treatment will be beneficial
- depression and social withdrawal
- financial difficulties
What are the DDx for back pain?
- mechanical lower back pain (inc lumbar spondylosis)
- prolapsed intervertebral disc
- malignancy
- cauda equina syndrome
- osteoprootic crush fracture
- seronagative spondyloarthropathy (HLA-B27-associated conditions)
- infection
- spinal canal stenosis
- non-spinal causes of back pain
What investigations should be done for back pain hx?
- Bedside
- back examination and lower limb neuro exam
- bloods
- bloods- FBC, LTS, U&Es, CRP and ESR
- Imaging
- If TB suspected: CXR and quantiferon-TB Gold (blood test to recognise TB)
- MRI (not needed if Hx suggests uncomp mech back pain)
- if cord compression or cauda equina suspected = Urgent MRI/CT scan
- If crush fracture suspected = x ray and subs DEXTA scan if a crush fracture is suspected
What is the management for back pain hx?
- Simple back pain inc prolapsed intervertebral disc
- advise to stay active and avoid prolonged bed rest
- physio regular analgesia and consider ST muscle relaxants
- serious pathology or red flag sx:
- cord compression = dexamethasone and urgent surgery; radiotherapy in malignancy
- cauda equina syndrome
- urgent surgery
- ankylosing spondylitis
- NSAIDs
- Osteoporosis
- bisphosphonates, vit D and calcium supplements
What are the S/Sx of mechanical lower-back pain in a back pain Hx?
- Usually is a localised pain that worsens with movement and changes in posture
- there maybe a hx of trauma/heavy lifting OR it could be spontaneous
- there will frequently be a Hx of previous similar episodes over a number of years
- no features of systemic illness nor neurological symptoms
What are the S/Sx of prolapsed intervertebral disc?
- Sudden, severe lower back pain often brought on by heavy lifting
- nerve-root involvement [most commonly sciatic nerve] classically causes a shooting pain down the leg that extends below the knee with paraesthesia in a dermatomal pattern
What are the S/Sx of a malignacy in a back pain hx?
- Unwell systemically e.g. weight loss and symptoms from primary malignancy
- usually of gradual onset with constant pain not relieved by rest
- PMHx of malignancy with tendency to metastatise to bone e.g. multiple myeloma, prostatic or breast carcinoma
What is are symptoms of cauda equina syndrome in a back pain Hx?
- Urinary and faecal incontinence
- sensory numbness of buttocks and backs of thighs & weakness of the legs [saddle anaesthesia]
- the most common causes of cauda equina (things putting pressure on the spinal cord) are malignancy and infection
What are the S/Sx of osteoporotic crush fracture in a back pain Hx?
- Risk factors for osteoporosis
- increasing age
- female sex
- corticosteroid therapy
- premature menopause (<40 years), smoking and malabsorption
- sudden localised back pain afer minimal trauma (even a sneeze)[e.g. ask what was happening immediately before the incident/pain]
What are the S/Sx of seronegative spondyloarthropathy (HLA-B27-associated conditions)? [in joint pain and back pain hx]
- ankylosing spondylitis
- psoratic arthritis
- enteropathic arthritis (from IBD)
- reactive arthritis (infection in GU/GI tract)
typically a young male of caucasian origin,
typically asymmetrical oligoarthritis affecting large joints, the spine is frequently involved with sacroiliitis most commonly and enthesitis
- Ank spond: 20-40y/o male, blurring of sacroiliac joints, pain, forward bend stiffness, progressive, electric type sciatic pain
morning back stiffness lasting > 1 hour which improves & the pain also with exercise
reduced range of movement of spine with characteristic question mark posture in the late stages
So particularly consider in a Hx of psoriasis/bowel disorders/recent infection
what are the S/Sx of infection in a back pain Hx?
- severe back pain in a systemically unwell patient with fever and night sweats
- past history of TB may suggest Potts disease
What are the S/Sx of spinal canal stenosis?
- associated with degenerative changes, so more common in an elderly population
- pain brought on by exercise and relieved by rest
- patient usually feels more comfortable in a slightly stooped forward position
What is spondyloLYSIS vs spondyloLISTHESIS, SpondyLITIS and spondyLOSIS?
LOSIS- degeneration of the intervertebral discs.
LYSIS- breakdown
LISTHESIS- prolapse disc and wedge fracture
LITIS- inflamamtion
