MSK - Level 2 Flashcards
Description of osteoarthritis?
Damage to synovial joints leads to repair and structural change
o May occur through repeated excessive loading and stress of joint over time, or by injury
Progressive loss of cartilage leads to exposed bone being sclerotic and increased vascularity
Osteophytes form
Epidemiology of osteoarthritis?
- Commonest joint condition
- Prevalence increases with age
- Females 3>1 Males
- Onset >50 years
Typical pattern in males and females of osteoarthritis?
- Females – hands and knees
- Males – hips
Risk factors of osteoarthritis?
o Familial o Age o Obesity o Joint damage or malalignment o Occupation/Sports
Symptoms in localised disease of osteoarthritis?
o Joint pain Worse on movement Relieved at rest Worse at end of day Joint gelling after 30 minutes of rest
o Crepitus, instability, loss of function
Symptoms in generalised disease of osteoarthritis?
o DIP, MCP, MTP and weight-bearing hips
Signs of osteoarthritis?
o Herbeden’s nodes (DIPs) o Bouchard Nodes (PIPs) o Joint tenderness, derangement o Decreased ROM o Mild synovitis o Muscle wasting o Baker’s cyst (OA/RA)
Diagnosis without imaging of osteoarthritis?
o If >45, has activity-related joint pain and NO morning stiffness or lasts <30 minutes
Investigations and their findings in osteoarthritis?
- CXR o Loss of joint space o Osteophytes o Subarticular sclerosis o Subchondral cysts - Raised CRP - Test for Rheumatoid if suspected
General Management of osteoarthritis?
o Leaflet/Arthritis UK website
o Exercise to improve local muscle strength and improve aerobic fitness
o Weight loss
o Appropriate footwear, cold packs, walking aids
o Local heat or ice can help
Analgesic management of osteoarthritis?
o Topical NSAIDs
o If ineffective, short-term oral NSAID (+PPI)
o Intraarticular steroid injection for moderate-to-severe pain
Refer if conservative measures fail
When to refer to surgeon in osteoarthritis? What options are available?
o When?
Joint replacement if impacting on QoL and refractory to non-surgical treatment
o Options?
Total joint replacement
Resurfacing
Fusion
Complications of osteoarthritis?
o Joint deformity
o Functional impairment
o Occupational impact
o Falls
Description of osteoporosis? What are osteoporotic fractures?
- Low bone mass and structural deterioration of bone tissue – leads to increase in bone fragility and susceptibility to fracture
- Osteoporotic fracture = fragility fracture occurring as consequence of osteoporosis
Definition of osteoporosis?
o Osteoporosis = Bone mineral density (BMD) of 2.5 SD below mean – measured by DEXA applied to femoral neck
o Osteopenia = BMD between -1 and -2.5 on DEXA
- It may be primary (age related) or secondary (to conditions or drugs)
Epidemiology of osteoporosis?
- Women mostly – due to decrease in oestrogen in menopause
- 1 in 3 women and 1 in 5 men will have fragility fracture
Risk Factors of osteoporosis - reduced bone mineral density?
DM, Hyperthyroidism, hyperparathyroidism IBD, Coeliac, pancreatitis CKD Liver failure COPD Menopause Immobility BMI<18.5
Risk factors of osteoporosis - does not reduce bone mineral density?
Age Oral corticosteroids Smoking Alcohol >3 units daily Previous fragility fractures RA Drugs – SSRIs, PPI, Carbamazepine
Symptoms of osteoporosis?
- Usually asymptomatic unless fragility fracture occurred
What are the at risk groups in osteoporosis?
Women >65, Men>75
Over 50 if: Previous osteoporotic fragility fracture Use of corticosteroids History of falls BMI <18.5 Smoker Alcohol >14 per week Secondary cause
Under 50 if:
Use of corticosteroids
Untreated premature menopause
Previous fragility fracture
Under 40 if:
>7.5mg prednisolone for >3 months
Previous or multiple fragility fracture
Consider in:
SSRIs, carbamazepine, GnRH, PPIs, pioglitazone
Testing for at risk groups in osteoporosis?
o Online risk calculator (QFracture/FRAX) to predict 10 year risk
If high (>10%) – DEXA scan to measure BMD
If borderline but risk factors – DEXA scan to measure BMD
When to test without calculating risk in osteoporosis?
- Dual-energy X-ray absorptiometry (DEXA) scan to measure BMD without calculating risk if:
o >50 with Hx of fragility fracture
o <40 with major risk factor for fractures
Bloods performed in osteoporosis?
o Bone screen - Ca, PO4 and ALP usually normal
Management if DEXA >-2.5 or low risk of fractures in osteoporosis? When to reassess?
Lifestyle advice
Regular exercise – walking outdoors, strength training
Eat balanced diet
Stop smoking
Drink within recommended alcohol limits
Reassess at minimum 2 years
Management if DEXA 2.5 or less in osteoporosis - drug treatment?
Bisphosphonate (alendronate 10mg OD or 70mg once weekly; risedronate 5mg OD or 35mg once weekly)
• Oral - if T-score <2.5 and QFRACTURE >1%
• IV - if T-score <2.5 and QFRACTURE >10% and cannot take oral
• Postmenopausal women and men >50
• Postmenopausal women alternative: Denosumab
If calcium adequate (>700mg/day)
• 400 units of colecalciferol daily
If calcium inadequate:
• 400 units of colecalciferol with 1000mg of calcium daily
HRT in women premature menopause (<40 years old)
Management if DEXA 2.5 or less in osteoporosis - lifestyle advice?
Regular exercise – walking outdoors, strength training
Eat balanced diet
Stop smoking
Drink within recommended alcohol limits
Management if DEXA 2.5 or less in osteoporosis - follow up?
Every 3-5 years
• If high risk – continue alendronate for 10 years (7 for risedronate)
• If not high risk – DEXA
o Continue if 2.5 and reassess after 2 years
Description of rheumatoid arthritis?
- Chronic systemic inflammatory disease characterised by symmetrical, deforming, peripheral polyarthritis
Pathology of rheumatoid arthritis?
- Affects typically small joints of hands and feet but can be at any synovial joint
- Synovial fluid inflammation leads to thickening of lining and infiltration by inflammatory cells
- Synovium proliferates over cartilage leaving ‘pannus’ – destroys cartilage and bone
Epidemiology of rheumatoid arthritis?
- 1% of population
- Females 2>1 Males
- Incidence increases with age
- Peak onset 50-60 years
Risk factors of rheumatoid arthritis?
o Women o Familial o Genetic HLA-DR4/DR1 o Smoking
Symptoms of rheumatoid arthritis?
o Typical
Symmetrical swollen, painful and stiff small joints of hands and feet
Worse in morning (>30 minutes of stiffness) and after activity
Joint instability, subluxation and dislocation
Many joints can be affected
o Less Common
Sudden onset, widespread arthritis
Recurring mono/polyarthritis
o Systemic Illness
Fatigue, fever, weight loss, pericarditis, pleurisy
Signs of rheumatoid arthritis?
o Early (inflammation, no joint damage) Swollen MCP, PIP, wrist, MTP joints
o Later (joint damage, deformity) Ulnar deviation of fingers Dorsal wrist subluxation Boutonnaire deformity Swan-neck deformity Z-deformity of thumbs Rupture of extensor hand tendons Similar foot deformities
Extra-articular signs of rheumatoid arthritis?
Nodules- elbows Lymphadenopathy Vasculitis/Alveolitis/Bronchiolitis Pleural/Pericardial Effusions Reynauds/Carpal tunnel syndrome/Peripheral neuropathy Splenomegaly Episcleritis/Scleritis Osteoporosis Felty's Syndrome (Splenomegaly, RA, pancytopenia)
When should you refer person with suspected rheumatoid arthritis?
- All suspected should be referred to early arthritis clinic
Bloods performed in rheumatoid arthritis?
o FBC – anaemia o CRP, ESR increased o LFTs, U&Es o Rheumatoid Factor Positive in 60-70% o Anti-Cyclic Citrullinated peptide antibodies (Anti-CCP) Highly specific o Antinuclear antibodies Positive in up to 30% of people
Imaging performed (if needed) in rheumatoid arthritis?
- X-Rays of hands and feet
o Soft tissue swelling, osteopenia, decreased joint space
o Later bony erosions, subluxation - Other options
o USS/MRI
o Aspiration
Sterile, high neutrophils
Diagnostic criteria of rheumatoid arthritis? When is diagnostic?
o People with >1 joint with definite swelling not explained by other disease
o Add total scores ≥6/10 is diagnostic
A – Joint Involvement (swelling or tenderness +/- imaging evidence) 1 large joint = 0 2-10 large joints = 1 1-3 small joints = 2 4-10 small joints = 3 >10 joints (≥1 small) = 5 B – Serology Negative RF & Anti-CCP = 0 Low +ve RF/Anti-CCP = 2 High +ve RF/Anti-CCP = 3 C – Acute phase reactants Normal CRP/ESR = 0 Abnormal CRP or ESR = 1 D – Duration of symptoms <6 weeks = 0 > 6 weeks = 1
Management in primary care of rheumatoid arthritis?
Referral needed if RA suspected
• Urgently if small joint of hands and feet affected, >1 joint or delay of 3 months or more between symptom onset and seeking medical advice
Analgesia
• Paracetamol with/without codeine
• If not controlled:
o NSAID/Coxib plus PPI
Secondary care investigations for diagnosis of rheumatoid arthritis?
- RF
- Anti-CCP (if RF negative)
- X-ray of hands and feet
Secondary care investigations following diagnosis of rheumatoid arthritis?
- Anti-CCP
- X-ray in hands and feet
- Functional ability (HAQ) for baseline
Management of flare up of rheumatoid arthritis?
Analgesia – NSAID, paracetamol, codeine
o Offer PPI
Corticosteroid injection o IA (methylprednisolone acetate or triamcinolone acetonide) o IM (methylprednisolone acetate or triamcinolone acetonide)
Oral prednisolone
Lifestyle advice given in rheumatoid arthritis?
- Manage CVD and BP
- Mediterranean diet
- Stop smoking
- Specialist Physiotherapy/OT
- Alcohol stop
- Pneumococcal and Influenza vaccine
Long-term management of rheumatoid arthritis - monitoring treatment response?
o CRP/ESR and disease activity using DAS28 score
Long-term management of rheumatoid arthritis - drug management?
1st step
o DMARD monotherapy within 3 months onset (1st-line)
Methotrexate, leflunomide or sulfasalazine
Consider hydroxychloroquine as alternative
2nd step
o Add another DMARD (oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) when remission/low disease activity not achieved
3rd step
o Add Biological Agents
Sarilumab + Methotrexate (if severe DAS28)
Others – adalimumab, etanerept, infliximab, certolizumab pegol, golimumab, tocilizumab, abatacept
4th Step
o Methotrexate + Rituximab
If severe and no response to other DMARDs, including at least 1 TNF inhibitor
Long-term management of rheumatoid arthritis - surgical management?
- Refer - pain, function, deformity or synovitis progressing despite optimal non-surgical management
- Refer – imminent or actual tendon rupture, nerve compression, stress fracture
Long-term management of rheumatoid arthritis - monitoring?
- 6 months after achieving remission or low disease activity
- Annual review – assess HAQ
- After 1 year of maintenance without steroids – consider stepping down dose of drug or stopping one DMARD
Description of polymyalgia rheumatica?
- Chronic, systemic inflammatory disease – characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle
- Usually >50 years old
Epidemiology of polymyalgia rheumatica?
- Most common inflammatory rheumatic condition in older people
- Same demographics as GCA
- Age >50
Risk factors of polymyalgia rheumatica?
o Older age - >65
o Females
o Northern European
o Infection (mycoplasma, chlamydia, parvovirus B19)
When to suspect polymyalgia rheumatica?
- Suspect in >50 with >2 week history of core symptoms:
o Bilateral shoulder and/or pelvic girdle pain
Worse with movement
Interferes with sleep
May radiate to elbows and knees
o Stiffness lasting >45 minutes
After waking or rest
May cause difficulty turning over in bed, rising from chair
Other features of polymyalgia rheumatica?
o Low grade fever, fatigue, anorexia and weight loss
o Peripheral MSK signs:
Carpal tunnel syndrome, peripheral arthritis, swelling of limbs
o NO WEAKNESS
Diagnosis of polymyalgia rheumatica?
o Core features
o Excluding conditions that mimic PMR
GCA, active infection/cancer, arthritis, thyroid disease, statin-induced, myositis
o Positive response to oral corticosteroids
Bloods to arrange in polymyalgia rheumatica?
o CRP raised
o ESR raised (can be normal)
o Arrange in all patients: TFT FBC LFT – raised ALP Protein electrophoresis CK levels normal RF Dipstick urinalysis
Tests to order if features of pathology in polymyalgia rheumatica?
Urine Bence Jones proteins
ANA
Anti-CCP
CXR
Management of polymyalgia rheumatica if most likely diagnosis?
- If PMR most likely diagnosis:
o Oral prednisolone 15mg OD
Follow up after 1 week to see response
o After 3-4 weeks – ESR/CRP and consider reducing dose
When to make working diagnosis of polymyalgia rheumatica? And management from there?
- Make working diagnosis of PMR if >70% improvement within 1 week and normalised ESR/CRP in 4 weeks
o If less response – increase dose to 20mg
o If still no response – refer to rheumatology
How to reduce prednisolone when fully controlled symptoms in polymyalgia rheumatica?
o 15mg 3-4 weeks o Then 12.5mg for 3 weeks o Then 10mg for 4-6 weeks o Then reduce by 1mg every 4-8 weeks until stopped o Lasts 1-2 years
General advice in polymyalgia rheumatica?
o Provide blue steroid card
o Immediate medical attention if symptoms of GCA
Follow up of polymyalgia rheumatica?
- Follow Up
o 1 week after dose change
o Every 3 months – BP, glucose - Asses osteoporosis fracture risk
When to refer to rheumatologist with atypical PMR with no alternative diagnosis?
o <60
o Red flags – weight loss, night pain, neurological symptoms
o Do not have core symptoms
o Normal ESR/CRP or very high
When to refer polymyalgia rheumatica for specialist management?
o Relapsing when reducing dose
o >2 years steroids
o Repetitive flares
o Lots of adverse effects
Complications of polymyalgia rheumatica?
o GCA and its complications - 15-20%
o Complications of long-term steroid use
Prognosis of polymyalgia rheumatica?
o Good – symptoms usually resolve within 24-72 hours
o 1-2 years of treatment is required
o Relapse common – responds to restarting or increasing dose of steroid
Description of gout?
- Raised uric acid level in blood and deposition of urate crystals in joints and tissues
- Gout tends to attack joints in extremities as temperature in feet low enough to precipitate urate from plasma
Pathology of gout?
o Hyperuricaemia results from overproduction of uric acid and renal underexcretion
o Urate derived from breakdown of purines (meat, peas, lentils, oats, mushrooms, spinach)
o Impaired excretion (Kidney disease, hypertension, Increased PTH, diuretics/aspirin, hypothyroidism)
o Increased production (Increased purines, PCV, Leukaemia, Carcinoma)
Epidemiology of gout?
- Most common inflammatory arthritis
- Men 10x, prevalence increases with age
- Prevalence increasing
Aetiology of gout?
o Cytotoxics o Hereditary o Increased dietary purines o Leukaemia o Diuretics o Alcohol o Associated CVD, HTN, DM, Renal failure
Symptoms of gout?
o Sudden onset, monoarticular pain, swelling and redness
o Most common MTP big toe, ankle, foot or hands
Investigations performed when gout suspected?
- Bloods
o FBC, CRP, U&Es, cholesterol, glucose
o May be done in primary care to find caused - Joint fluid microscopy and culture
o Urate crystals – negatively bifringent
o Rule out septic arthritis - X-ray
o Soft-tissue swelling, then punched-out lesions in peri-articular bone - Serum Uric Acid
o Done 4-6 weeks after acute attack to confirm increased uric acid
Management of acute attack of gout?
o General Advice
Bed-rest
Elevate and ice joint
Keep joint in cool environment
o Drug Treatment
NSAIDs (Diclofenac 75mg bd or if CI colchicine 500mcg bd)
Continue until 1-2 days after acute attack resolved
Do not alter treatment if patient on long-term gout treatment
Oral steroids could be used if NSAIDs CI (prednisolone 15mg od for 5 days)
o Follow Up after 4-6 weeks
Serum uric acid after 4-6 weeks (Aim <300micromol/L)
Measure BP, HbA1c, U&E and lipids
Prevention advice of gout?
o Lose weight o Regular exercise o Stop smoking o Reduce alcohol intake o Stop diuretics o Diet – reduce cholesterol, avoid sugar-sweetened soft drinks avoid purine rich foods (meats and seafood)
Drug prevention in gout?
Allopurinol
o after 1st attack of gout
o Start at 100mg (50 if renal impairment) OD, increased in increments of 100mg every 4 weeks until SUA <360 (<300 if frequent flares or tophi)
o Commence after acute attack when not in pain
Colchicine cover with starting allopurinol
Alternative – febuxostat 80mg OD, up to 120mg OD
When to refer to rheumatologist in gout?
o Diagnosis uncertain or during pregnancy or <30
o Persistent symptoms on maximum anti-inflammatory medication
o Intra-articular steroid injection
o Person requires urate-lowering therapy but allopurinol and febuxostat CI or not tolerated
o Complications present
Prognosis of gout?
o Self-limiting – usually resolve within 1-2 weeks
o Around half recur within a year
Complications of gout?
o Tophi occurs in 50% with untreated gout – may become inflamed and infected
o Urinary stones common in people with gout
o Risk factor for chronic kidney disease
Description, symptoms, investigations and management of pseudogout?
o Calcium pyrophosphate deposition in hyaline and fibrocartilage
o Typically affects knees, wrists, hips of elderly with history of arthritic attacks
o Associated with hyperparathyroidism, haemochromatosis, Wilson’s disease, hypothyroidism
o X-rays show chondrocalcinosis in joint menisci, tendon insertion, ligament, bursa
o Aspiration – weakly positively bifringent crystals on microscopy
o Rx – NSAIDs and rest
Description of vasculitis?
- Inflammatory disorder of blood vessel walls, causing destruction (aneurysm/rupture) or stenosis
- Can be primary (occurring on own) or secondary (SLE, RA, hepatitis B/C, HIV)
Classification of vasculitis - large vessel?
Giant cell arteritis
Takayasu’s arteritis
Classification of vasculitis - medium vessel?
Polyarteritis Nodosa
Kawasaki Disease
Classification of vasculitis - small vessel?
ANCA positive • P-ANCA – microscopic polyangiitis, glomerulonephritis, Churg-Strauss syndrome • C-ANCA – Wegener’s granulomatosis ANCA negative • Henoch-Schonlein purpura • Goodpasture’s syndrome • Cryoglobulinaemia Other Causes: • SLA, RA, IBD • Drugs – sulphonamides, Beta-lactams, quinolones, NSAIDs , OCP, thiazides • Neoplasm – hairy cell leukaemia
Symptoms of vasculitis - large vessel?
End-organ (TIA/CVA) Hypertension Aneurysms Dissection Visual changes, jaw claudication
Symptoms of vasculitis - medium vessel?
Ulcers Digital infarcts Nodules Livedo reticularis Papulo-necrotic lesions Hypertension
Symptoms of vasculitis - small vessel?
Palpable purpura 1-3mm Tiny papules Spinter haemorrhages Urticaria Vesicles Haematuria
Specific symptoms depending on organs affected in vasculitis?
o Systemic – fever, malaise, weight loss, arthralgia, myalgia
o Skin – purpura, ulcers, livedo reticularis, splinter haemorrhages, digital gangrene
o Eyes – episcleritis, slceritis, visual loss
o ENT – epistaxis, nasal crusting, stridor
o Pulmonary – SOB, haemoptysis
o Cardiac – angina, MI, heart failure, pericarditis
o GI – pain, malabsorption
o Renal – hypertension, haematuria, proteinuria, casts, renal failure
o Neuro – TIA/CVA, fits, chorea, psychosis, confusion, altered cognition
o GU - orchitis
Investigations performed in vasculitis?
- Bloods o FBC, U&E, LFT o CRP/ESR o ANCA o RF o Anti-CCP - Urine dip, microscopy and culture - Biopsy - Echocardiogram and blood cultures if murmur
Management of vasculitis?
- Referral to rheumatologist
- Specific Treatments
o Large Vessel – Steroids (Azathioprine) + bisphosphonates
o Medium/Small Vessels – Steroids and IV cyclophosphamide (Azathioprine)
o ANCA positive – Mycophenolate mofetil
What is Wegener’s granulomatosis?
- Granulomatosis with polyangiitis
- Necrotising granulomatous inflammation and vasculitis of small and medium vessels (predilection for lungs, URT, kidneys)
Symptoms of Wegener’s granulomatosis?
o Nasal obstruction, ulcers, epistaxis, saddle nose deformity
o Glomerulonephritis - Proteinuria, haematuria
o Cough, haemoptysis
o Skin purpura, mononeuritis multiplex, arthritis, keratitis, scleritis, episcleritis
Tests performed in Wegener’s granulomatosis?
o cANCA
o Raised ESR/CRP
o Urinalysis – proteinuria, haematuria
o CXR – nodules and fluffy infiltrates
Management of Wegener’s granulomatosis?
o Prednisolone and cyclophosphamide
o Azathioprine and methotrexate (steroid sparing)
o Co-trimoxazole prophylaxis against PCP
Description of Takayasu’s arteritis?
- Systemic vasculitis affecting aorta and major branches
- Granulomatous inflammation causes stenosis, thrombosis and aneurysm
- Rare outside Japan, affects 20-40
Symptoms of Takayasu’s arteritis?
- Symptoms
o Dizziness, visual changes, weak arm pulses, fever, malaise - Complications
o Aortic regurgitation, aortic aneurysm, dissection, stroke, IHD
Diagnossi of Takayasu’s arteritis?
o ESR, CRP raised
o MRI
Management of Takayasu’s arteritis?
o Prednisolone
o Methotrexate or cyclophosphamide if refractory
o Angioplasty +/- stenting
Description of Kawasaki Disease?
- Systemic vasculitis with coronary arteritis – coronary artery aneurysms
- Commonest cause of acquired child heart disease
Diagnostic criteria of Kawasaki Disease?
o Fever for 5 days and 4 out of 5 of following:
Conjunctivitis without pus
Cervical lymphadenopathy
Extremity changes – swelling of hands/feet and desquamation
Rash
Lips- red, cracking or strawberry tongue
Investigations of Kawasaki Disease?
o Bloods – CRP and ESR raised
o ECG and echo to rule out CV complications
Management of Kawasaki Disease?
o High dose IV immunoglobuilin 2g/kg within 10 days
o Corticosteroids - prednisolone -if IV-ImmunoGlobulin ineffective
o Aspirin 30-50mg continued for atleast 6 weeks
Description of Henoch-Schonlein Purpura?
- Acute IgA mediated vasculitis causing medium sized artery inflammation
- Occurs between 3-10, boys mostly
- Aetiology – infection (group-A strept, mycoplasma, EBV, drugs and allergies
Symptoms of Henoch-Schonlein Purpura?
o Preceding URTI in 50-90% cases
o Skin Rash
Symmetrical, palpable purpura over buttocks, extensor surfaces, arms, legs and ankles
Initially uticarial -> becoming maculopapular -> subsequently purpuric
Recurs over several weeks
o Arthralgia
Knees and ankles mainly
o Colicky Abdo Pain
Intussusception (2/3%)
o Renal Nephropathy
80% of cases have micro/macro-scopic haematuria or mild proteinuria
Complete recovery is normal but if proteinuria is severe, nephritic syndrome
o Scrotal Oedema
Investigations of Henoch-Schonlein Purpura?
o Mid-stream urine – protein and haematuria
o BP
o Bloods – FBC, ESR, U&E, IgA
o Imaging – Renal US and biopsy
Management of Henoch-Schonlein Purpura?
o Most resolve in <2 months
o Usually self-limiting, regular paracetamol and NSAIDs may help joint pain but caution in renal insufficiency
o If severe, prednisolone may help resolve abdominal pain
o May require admission to hospital for monitoring of abdominal and renal complications
Description of Goodpasture’s syndrome?
- Acute glomerulonephritis + lung involvement (haemoptysis, diffuse pulmonary haemorrhage)
- Caused by anti-GBM antibodies (bind to kidney basement membrane and alveolar)
Management of Goodpasture’s syndrome?
- Tests – CXR, renal biopsy
- Management – prednisolone and plasmaphoresis
Description of low back pain?
- Pain in lumbosacral area of back, between buttocks and bottom of ribs
- Specific causes – sciatica, vertebral fracture, intra-abdominal pathologies and rare, ankylosing spondylitis, cancer and infection
- Non-specific when no specific cause and may be due to trauma or MSK injury
How common is low back pain?
- 60% people have low back pain in their life
Risk factors of low back pain?
o Obesity
o Physical inactivity
o Heavy lifting
o Depression
Symptoms of non-specific back pain?
o Pain varies with posture and time, exacerbated by movement
Red flag symptoms needing investigation in low back pain?
o Cauda equina syndrome – bilateral neurological deficit of legs, urinary retention/incontinence, faecal incontinence, perianal sphincter loss, saddle anaesthesia
o Cancer of spine - >50, gradual onset, unremitting pain, remains when supine and aching at night that disturbs sleep, spinal tenderness, unexplained weight loss, Hx of cancer
o Spinal fracture due to trauma or osteoporosis – sudden onset, severe central spinal pain, relieved by lying down, history lf major trauma, deformity of spine, tenderness
o Spinal infection – fever, TB, diabetes, IVDU, HIV
Management of low back pain - if red flag symptoms?
- If red flag symptoms – admit or refer urgently for assessment
Management of non-specific back pain?
o Risk stratification STarT Back to identify risk factors
o Self-Management Advice
Exercises - leaflets
Local heat
Stay active and resume normal activities and work as soon as possible
o Analgesia
NSAIDs (ibuprofen or naproxen)
Codeine 2nd line
If muscle spasm – give diazepam 2mg up to TDS for 5 days
o Group exercise programmes
o CBT if psychological element
Management of low back pain - if initial management not working for patient?
o Radiofrequency denervation if supplied by medial branch nerve
o Spinal cord stimulation
Follow up in low back pain?
o If worsening or persist after 3-4 weeks, come back to GP
Prognosis of low back pain?
- Non-specific back pain resolves within 4 weeks usually
- May have episodes of recurrence
Description of prolapsed disc?
- Part of nucleus pulposus herniates through weakness in outer part of disc
- Majority L4/5 or L5-S1
Pathology of prolapsed disc?
o Usually occur postero-laterally when annulus fibrosis is thin and not supported by longitudinal ligaments
o Herniation will impinge on nerves below
Epidemiology of prolapsed disc?
- Degeneration of disc
- Trauma
- General wear and tear
- Lifting heavy loads
Aetiology of prolapsed disc?
- Degeneration of disc
- Trauma
- General wear and tear
- Lifting heavy loads
Symptoms of prolapsed disc?
- Sudden, onset, severe back pain – usually following strenuous exercise
- Clearly related to position and aggravated by movement
- Radiation depends on nerve impingement:
o S1 – buttock to back of foot
o L5 – Buttock to lateral leg and dorsal foot
o L4 – Lateral aspect of thigh to medial calf - Typically, one sided but can be bilateral if large
- Bowel & Bladder incontinence
Signs of Cauda Equina Syndrome?
- Bilateral root pain in legs
- Saddle anaesthesia
- Loss of anal tone PR
- Bladder + Bowel incontinence
Imaging of prolapsed disc?
- X- rays often normal
- Need good examination
- MRI diagnostic and can identify for surgery
Management of prolapsed disc?
Symptomatic relief - NSAIDs, paracetamol, codeine, bed rest Steroid injection Physio & Exercise Surgery (if worsening, not settled in 6 weeks)
Description of sciatica?
- Sciatic nerve L4-S3
- Symptoms arise from impingement of lumbosacral nerve roots and felt in sciatic dermatome
Epidemiology of sciatica?
- Around 15-40% of patients experience sciatica at some point during lifetime
- Incidence related to age, peaking in 5th decade
- Rarely seen before 20
Risk factors of sciatica?
- Strenuous physical activity
- Whole body vibration
- Smoking, obesity, occupational factors
Causes of sciatica?
- Slipped disc (90% of cases)
- Spondylolisthesis – proximal vertebra moves forward relative to distal vertebra
- Spinal stenosis
o Narrowing of spinal canal – pain relived by forward flexion and worsened on extension - Infection and Cancer (rare)
Symptoms of sciatica?
- Affect hamstrings and all muscles below knee (foot drop), with loss of sensation below knee laterally
- Unilateral leg pain radiating below the knee to the foot or toes
- Low back pain – not too severe
- Numbness, tingling (paresthesia) and muscle weakness in dermatome
Red flags in back pain of sciatica?
- Cauda equina syndrome
- Spinal fracture
o Sudden onset relieved by lying down
o Hx of trauma, strenuous lifting, osteoporosis
o Point tenderness over vertebral body - Cancer
o >50, gradual onset of symptoms
o Severe, unremitting pain – aching at night, unexplained weight loss - Infection (discitis, vertebral osteomyelitis, spinal epidural abscess)
o Fever, TB, diabetes, Hx of IVDU, HIV
When to refer sciatica?
- Urgent referral if red flag suspicion
General advice in sciatica?
- Use STarT Back to identify risk factors
- Self-management advice
o Information – symptoms usually settle in 4-6 weeks
o Local heat may help
o Small firm cushion between knees while sleeping
o Leaflets
o Encourage active, normal daily activities
Analgesia in sciatica?
o NSAIDs (ibuprofen, naproxen) +/- paracetamol o Add amitriptyline, duloxetine, gabapentin, pregabalin o Benzodiazepines (diazepam 2mg TDS up to 5 days) for muscle spasm
Follow up of sciatica?
- Seek follow-up if worsening or not improving after 2-3 weeks
Management options in certain groups of patients for sciatica?
- Group exercise programme (biomechanical, aerobic)
- Physiotherapist
- CBT if they have psychosocial obstacles to recovery
Complications of sciatica?
- Permanent nerve damage with possible sensory deficits and motor weakness, such as foot drop
- Anxiety, depression and psychosocial impact
- Time off work, loss of employment
Prognosis of sciatica?
- Usually transient with improvements seen within weeks or a few months
- Poorer prognosis seen in women, more severe sciatica
- May have recurrence of symptoms
Definition of spondyloarthritis?
o Group of inflammatory rheumatologic conditions
o Can be axial (affecting sacroiliac joints and spine) or peripheral (psoriatic arthritis, reactive arthritis, enteropathic spondyloarthritis)
Description of ankylosing spondylitis?
- Ankylosing Spondylitis (radiographic axial spondyloarthritis)
o Inflammatory axial spondyloarthritis with sacroilitis on x-ray is characteristic
Epidemiology of ankylosing spondylitis?
- Prevalence 0.25-1%
- 3x more common in men and present earlier than women
- Present between 20-30
Aetiology of ankylosing spondylitis?
- Unknown aetiology
- 90% HLA B27 positive
Symptoms of ankylosing spondylitis?
- Gradual onset, recurrent low back pain and stiffness
o Worse at night with spinal morning stiffness (>30 minutes)
o Relieved by exercise - Pain radiates from sacroiliac joint to hips and buttocks
- Loss of spinal movement due to new bone formation (SI ankylosis and syndesmophytes (bony growths in intervertebral joint ligaments)
- Fatigue
Signs of ankylosing spondylitis?
- Kyphosis and neck hyperextension
- Dactylitis (swelling of fingers and toes)
- Arthritis
- Enthesitis – inflammation of site of tendon/ligament insertion (costchondritis, plantar fasciitis, Achilles tendonitis)
- Acute anterior uveitis
Blood tests & imaging to perform in patient suspected of ankylosing spondylitis?
- Bloods in primary care
o ESR, CRP, FBC (normocytic anaemia) - Local guidelines on X-ray (sacroiliitis), MRI, USS
o Sacroiliitis, sclerosis, erosions, total or partial ankylosis (fusion of joints)
Management if ankylosing spondylitis suspected?
o Refer to rheumatologist
Diagnostic criteria of ankylosing spondylitis?
o Modified New York Criteria
o ASAS classification criteria
Criteria of Modified New York Criteria in diagnosing ankylosing spondylitis?
o Modified New York Criteria
Diagnosed if
• At least 1 clinical criteria + radiological criteria
• All 3 clinical criteria without radiological evidence
Clinical
• Low back pain - >3 months, improved by exercise but not relieved by rest
• Limitation of lumbar spine movement in sagittal and frontal planes
• Limitation of chest expansion
Radiological criteria
• Sacroiliitis on XR
Criteria for ASAS classification criteria in diagnosing ankylosing spondylitis?
o ASAS classification criteria (for people with back pain for 3 months or more who were <45 at onset)
Sacroiliitis on imaging plus 1 or more feature of spondyloarthritis OR
HLA-B27 plus 2 or more features of spondyloarthritis
• Features = inflammatory back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis, IBD, response to NSAIDs, FHx, high CRP
Imaging performed in ankylosing spondylitis?
o XR of sacroiliac joints
when can you diagnose ankylosing spondylitis?
XR shows sacroiliitis with New York criteria bilateral grade 2-4 or unilateral 3-4
Imaging if XR does not show sacroilitis but high NY score?
Unenhanced MRI
General advice in suspected ankylosing spondylitis?
o Chronic condition and no cure – need referral for confirmation
o Exercise – maintain posture and mobility
o If chest wall restriction – influenza and pneumococcal vaccine
Anaglesia in suspected ankylosing spondylitis?
o NSAIDs with PPI
o Add paracetamol and codeine if NSAIDs CI
o Corticosteroid injection for sacroiliitis/enthesitis
When to refer to rheumatologist in ankylosing spondylitis?
- Referral to rheumatologist if low back pain starting before 45 and lasting >3 months, plus 4 or more of the following:
o Low back pain starting before 35
o Symptoms wake during second half of night
o Buttock pain
o Improvement when moving
o Improvement within 48 hours of NSAIDs
o 1st degree relative with spondyloarthritis
o Current or past arthritis
o Current or past enthesitis
o Current or past psoriasis - If 3 are present – perform HLA-B27 test – if positive, refer to rheumatologist
Management of confirmed ankylosing spondylitis in primary care?
o Analgesia
NSAIDs with PPI
Add paracetamol and codeine if NSAIDs CI
o Flare Management
Referral to secondary care – if recurrent flare ups, taking DMARDs, or comorbidities
o 2-yearly osteoporosis DEXA scan
o Manage modifiable risk factors
CVD, hypertension, lipid modification, obesity, smoking cessation
o Referral
Ophthalmology if anterior uveitis suspected
Rheumatology if symptoms not controlled
Management of confirmed ankylosing spondylitis in secondary care - non-pharmacological?
- Specialist physiotherapy
o Stretching, strengthening, postural exercises, deep breathing, range of motions - Consider hydrotherapy
Management of confirmed ankylosing spondylitis in secondary care - pharmacological?
- NSAIDs (at lowest effective dose) + PPI
o If taken for 2-4 weeks and not adequate – switch NSAIDs - Biological DMARDs (assess after 12 weeks)
o TNF-alpha inhibitors (adalimumab, etanercept, golimumab, infliximab) – severe and not responding to NSAIDs
o Secukinumab – if not responded to NSAIDs or TNF-alpha inhibitors
Management of confirmed ankylosing spondylitis in secondary care - surgical?
o Refer when spinal deformity significantly affecting ADLs and severe or progressive despite optimal treatment
Managing flare ups of ankylosing spondylitis?
o Flare management plan with access to care, self-care advice, pain management and changes to medications
Prognosis of ankylosing spondylitis?
- 70-90% of those affected remain fully independent or minimally disabled long term
- Spinal deformities may occur usually after 10 years
- Worse prognosis in ESR >30, onset <16 and early hip involvement
COmplications of ankylosing spondylitis?
- Aortic regurgitation
- Anterior uveitis
- AV node block
- Achilles’ tendon rupture
- Spinal fractures
- Fixed and flexed posture
- Osteoporosis
- Cauda equina syndrome
Definition of reactive arthritis?
- Seronegative spondyloarthritis, typically affecting lower limbs 1-4 weeks after urethritis (chlamydia ureaplasma) or dysentery (Campylobacter, salmonella, shigella, Yersinia)
What is Reiter’s syndrome?
- Reiter’s syndrome – triad of urethritis, arthritis and conjunctivitis
Epidemiology of reactive arthritis?
- Young white adults
- Associated with HLA-B27
Risk factors of reactive arthritis?
- Post-venereal – Chlamydia, HIV
- Post-enteric – Campylobacter, Salmonella, Shigella
Symptoms of reactive arthritis?
- Symptoms 2-4 weeks after GU or GI infection
o Acute malaise, fatigue and fever
o Asymmetrical lower limb oligoarthritis
o Low back pain
o Enthesitis
o May be iritis, keratoderma blenorrhagica (brown, raised plaques on soles and palms), circinate balanitis (painless penile ulceration), mouth ulcers
Investigations of reactive arthritis?
- Bloods
o Raised ESR/CRP
o FBC – normocytic, normochromic anaemia, mild leucocytosis and thrombocytosis
o HLA-B27 positive - Joint aspiration to rule out septic arthritis
o High WBC count (polymorphonuclear leukocytes) - Culture of stools, throat and urogenital tract to identify causative organism
Management of reactive arthritis?
- Immobilise affected joints
- NSAIDs
- Prednisolone – oral/intra-articular/topical
- If symptoms >6 months – DMARD - sulfasalazine or methotrexate
Prognosis of reactive arthritis?
o Usually self-limiting with resolution in 3-12 months, may persist
Complications of reactive arthritis?
o Osteoarthritis
o Iritis/Uveitis
Description of polyarteritis nodosa?
Necrotising vasculitis causing aneurysms and thrombosis of medium-sized arteries, leading to infarction in organs (renal) with systemic symptoms
Epidemiology of polyarteritis nodosa?
Women 2x
Associated conditions of polyarteritis nodosa?
Hep B
Symptoms of polyarteritis nodosa?
Systemic features - fever, weight loss, headache, myalgia
Neuro - mononeuritis multiplex
Skin - livedo reticularis rash and punched out ulcers
Renal - ischaemia
Cardiac, GU and GI involvementt
Tests of polyarteritis nodosa?
Bloods - raised WCC, mild eosinophilia, anaemia, high
Hep B surface antigien positive 30%
ESR/CRP
ANCA negative
Renal/abdominal angiography - diagnostic of multiple aneurysms
Management of polyarteritis nodosa?
Control BP
Steroids and azathioprine/cyclophosphamide
Definition of Churg-Strauss Syndrome?
ANCA positive vasculitis affecting small arteries
Triad of adult-onset asthma, eosinophilia and vasculitis affecting lungs (pulmonary infiltrates), skin, nerves (mononeuritis multiplex) and heart
Symptoms of Churg-Strauss Syndrome?
Systemic - fever, joint pain, muscle pain, weight loss, chest pain
Pulmonary - asthma, pneumonitis
URTI - sinusitis, rhinitis
Heart - HF, myocarditis, MI
Skin - purpura, skin nodules, livedo reticularis
Renal - CKD, hypertension, glomerulonephritis
Nerves - mononeuritis multiplex
Investigations of Churg-Strauss Syndrome?
ANCA - pANCA positive in 30%
FBC - eosinophilia, high ESR/CRP
U&E - high creatinine
CXR - pulmonary opacities
Management of Churg-Strauss Syndrome?
Steroids
Cyclophosphamide if severe
Rituximab if refractory disease
Definition of Microscopic polyangiitis?
Necrotizing vasculitis affecting small and medium sized vessels
Symptoms of Microscopic polyangiitis?
Rapidly progressing glomerulonephritis
Pulmonary haemorrhage
Investigations of Microscopic polyangiitis?
pANCA positive
Management of Microscopic polyangiitis?
Control BP
Steroids and azathioprine/cyclophosphamide
Definition of Behcet’s disease?
Systemic inflammatory disease with recurrent oral ulcers, associated with HLA-B5
Epidemiology of Behcet’s disease?
Most common along old Silk Road - Mediterranean to China
Age 20-30
Symptoms of Behcet’s disease?
Recurrent oral and genital ulceration
Uveitis
Skin (erythema nodosum, papulopustular lesions)
Arthritis (non-erosive large joint oligoarthritis)
Vasculitis
Pathergy - exaggerated skin injury occuring after minor trauma
Myo/pericarditis
Colitis
CNS - memory impairment, pyramidal signs
Diagnosis of Behcet’s disease?
Clinical
Pathergy test - needle prick leads to papule formation within 48 hours
Management of Behcet’s disease?
Topical steroids for oral/genital ulcers
Azathioprine/Cyclophosphamide for systemic disease
Infliximab
Definition of Buerger’s Disease?
Called thromboangiitis obliterans
Non-atherosclerotic smoking-related inflammation and thrombosis of veins and middle-sized arteries causing thrombophlebitis and ischaemia (ulcers and gangrene)
Men aged 20-45
Aetiology of Buerger’s Disease?
Unknown but smoking leads to development/progression of disease
Symptoms of Buerger’s Disease?
Claudications in feet/hands or pain at rest
Begins in extremities and may radiate centrally
Discolouration of limbs, symptoms worsen with cold or stress, numbness or tingling, Raynauds’ phenomenon, skin ulcers, digital gangrene
Investigations of Buerger’s Disease?
To rule out other vasculitis - FBC, LFTs, U&E, glucose, ESR, CRP, autoantibodies
Imaging - angiography - corkscrew appearance of arteries
Management of Buerger’s Disease?
Stop smoking!!
Avoid cold, sitting or standing in one position for long
Avoid tight clothing
Aspirin/Iloprost
