OA Flashcards
List 8 causes of low back pain
Facet joint OA
Disc degeneration
Disc herniation
Inflammatory back pain
Fractures
Malignancy
Infection
Intra-abdominal pathology
What are the 2 types of disc herniation seen in low back pain and what are the possible complications of these?
Central: can cause canal stenosis
Posterolateral: can cause radicular impingement
List 3 causes of inflammatory back pain
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis/Reiter’s syndrome (term not used much anymore)
Why is it important to investigate the cause of lower back fractures?
May be due to osteoporosis, malignancy or trauma
What malignancies commonly metastasise to bone and how are these classified?
Osteolytic (common): breast, lung, thyroid, renal, adrenal, GI
Osteosclerotic: prostate, TCC
Mixed: breast, lung, prostate
List 3 infectious causes of low back pain
Discitis
Osteomyelitis
Epidural abscess
List 3 intra-abdominal pathologies which can cause low back pain
AAA
Renal pathology
Pelvic pathologies
What is the usual anatomical cause of spinal canal stenosis resulting in radiculopathy?
Combination of:
Facet joint OA (narrowing of disc space, formation of osteophytes)
Ligamentum flavum hypertrophy
Bulging or thinning of intervertebral disc, resulting in herniation
NB It is thought that these changes result in impedance of venous outflow and arterial inflow, causing nerve root ischaemia and pain
What clinical syndrome does lower (L4/5) spinal canal stenosis cause? Why?
Lumbar claudication
Due to compression of nerve roots
What are the hallmark features of lumbar claudication?
Lumbar, buttock or thigh pain
Usually uni- but may be bi-lateral
Not present at rest
Comes on with exercise at a reproducible walking distance
Given that degenerative changes in the lumbar spine are common beyond a certain age and not diagnostic, what MRI changes in the lumbar spine are more common in patients with back pain?
Disc bulge (most often seen, but seen frequently in those without back pain)
Disc protrusion (can also be commonly seen without back pain)
Disc extrusion (rarely seen in those without back pain)
When is a full neurological examination warranted in a patient with lower back pain?
In the presence of lower limb pain and other neurological symptoms
How reliable and valid are clinical signs detected during physical and psychosocial examination?
Interpret with caution
What ancillary investigations are not routinely recommended in a patient with acute non-specific lower back pain?
Plain X-rays of lumbar spine (of limited diagnostic value and give no benefits in physical function, pain or disability)
List 4 features/risk factors an infectious cause of acute low back pain
Symptoms and signs of infection (e.g. fever)
Underlying disease process
Immunosuppression
Penetrating wound
List 2 features/risk factors for fracture as a cause of acute low back pain
History of trauma
Minor trauma if >50 years, history of osteoporosis and taking corticosteroids, history of malignancy
List 6 features/risk factors for tumour as a cause of acute low back pain
Past history of malignancy
Age >50 years
Failure to improve with treatment
Unexplained weight loss
Pain at multiple sites
Pain at rest or at night (pretty non-specific; can get this with advanced OA)
What might the absence of aggravating features for acute low back pain indicate?
Aortic aneurysms
What is the timeline for recovery for a patient with a short duration of low back pain?
Majority recover within 3/12 (often persistence of milder symptoms)
NB Recurrences are common
What factors are associated with progression from acute to chronic low back pain?
Psychosocial and occupational factors (“yellow flags”; should be assessed early to facilitate intervention)
What is the first line treatment for simple back pain, and OA hip and knee pain?
Paracetamol in regular divided doses to a maximum of 4 g/day
NB Not as effective as NSAIDs but lower risk of AEs
What is the verdict on NSAID use in OA?
Short term may be useful; use where simple analgesia and non-pharmacological measures are ineffective
Early in its natural history OA is often inflammatory - late OA is usually not
Consider AEs, esp in elderly and those on concomitant Rx (careful BP and renal function monitoring indicated, consider prescribing alongside a PPI or COX-2 inhibitor)
Mrs Ierino, 55 year old woman, presents with increasing pain in the R buttock and groin on walking; pain began about 2 years ago but was intermittent and not severe
In last few months the pain is present when walking and limits her ability to climb stairs
Pain radiates to lateral thigh
What are the key points in the Hx?
Age
Time frame (chronic)
Distribution of pain
Presence of any low back pain
Presence of neurological Sx (e.g. parasthesia, numbness)
Previous injury
FHx of arthritis
What secondary problems can develop as a result of abnormal gait in hip OA?
Trochanteric bursitis
Gluteal tendonopathy
Is it common for hip pain to refer posteriorly?
No; some patients with hip pain refer posteriorly but uncommonly
What nerve roots are usually impinged in sciatica?
S1/S2 (posterior)
What nerve roots are likely compressed if the patient has lateral thigh pain?
L4/L5
What nerve roots are likely compressed if the patient has groin pain?
L1/L2
Mrs Ierino’s groin and thigh pain is worse with walking and better with rest; there is some associated lower back pain
Has stopped walking any distance due to pain
Paracetamol is helpful
Reluctant to take NSAID as she had a gastric ulcer 2 years ago after taking diclofenac for pain
PHx: HTN for 10 years treaed with indapamide 2.5mg daily, T2DM diagnosed 6 years ago, treated with metformin 500mg BD, bleeding gastric ulcer 2 years ago after using diclofenac
FHx: mother had AMI at 62
SHx: married with 2 children and 1 grandchild, husband works fulltime in family dry-cleaning business
What are the most common causes of mechanical low back pain?
Facet joint OA
Disc degeneration
Disc herniation: central (can cause stenosis) or posterolateral (can cause radicular impingement)
Identify 3 common causes of mechanical lower back pain
Facet joint OA
Disc degeneration
Disc herniation (central or posterolateral)
Mrs Ierino, 55 year old woman, presents with increasing pain in the R buttock and groin on walking (radiates to lateral thigh), better with rest (some associated lower back pain); pain began about 2 years ago but was intermittent and not severe
In last few months the pain is present when walking and limits her ability to climb stairs; she has recently stopped walking any distance due to the pain
Paracetamol is helpful but she is reluctant to take an NSAID as she had a gastric ulcer 2 years ago after taking diclofenac for back pain
PHx: HTN for 10 years treated with indapamide 2.5mg daily, T2DM diagnosed 6 years ago treated with metform 500mg BD, bleeding gastric ulcer 2 years ago after using diclofenac
FHx: mother had AMI at age 62
SHx: married with 2 children and 1 grandchild, husband works fulltime in family dry cleaning business
What steps are involved in the hip and back examination for Mrs Ierino?
Hip: look (including gait, Trendelenberg test), feel for back or soft tissue tenderness and around the pelvic brim (one side may be elevated due to a leg length discrepancy or scoliosis), move through full ROM, always watch the patient performing functional movements (getting up on the couch, doing a log roll, etc)
If groin pain also check for inguinal hernias
Back: look (for posture, curvatures, scoliosis), feel for vertebral or paravertebral (muscle spasm) tenderness, move through flexion/extension/lateral flexion/rotation, special tests including straight leg raise and Schober’s test
What are the 3 “red flag” conditions?
Infection
Fracture
Malignancy
How is Schober’s test performed and how is it interpreted? What is it usually used for?
Place fingers 15cm apart on back starting from level of L4, ask patient to touch toes, check to see if the distance increases to >20cm
If <20cm, suggests ankylosing spondylitis, OA or muscular spasm
Mostly used to monitor ankylosing spondylitis over time
What might a waddling gait suggest?
Proximal myopathy
What is a positive straight leg raise and what nerve roots does the straight leg raise test?
Pain before 60 degrees of motion is a positive test
Tests L5/S1 (sciatica)
How is the Trendelenberg test interpreted?
If non-stance hip sags, the problem is with the stance side
Usually indicates weakness of adductor muscles gluteus medius and minimus (although be careful with interpretation - may also be effort on part of patient to reduce pain)
What movement is most affected and affected earliest in hip OA?
Internal rotation
What factors result in the poor pain localisation and complex patterns of referred pain in back and hip pathology?
List 6 signs of scoliosis
How is scoliosis classified based on XR? How can imagining inform Mx?
Simple C or compound S shaped
Radiologists calculated COB angle
Mr Mohamed, a 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box
DDx?
Muscle spasm/tear
Disc herniation/bulge
Fracture
Infection (ask about Hx of IVDU)
LIgamentous damage
Inflammatory spondyloarthropathy
What is this sign called? What pathological changes are seen on this XR? What kind of fracture can be detected with this XR view?
Summation shadows of 2 overlapping lumbar vertebrae in the oblique view plain XR are said to resemble the outline of a “scotty dog”
This example shows some facet joint OA (aka degenerative changes), including joint space narrowing and sclerosis
Fracture of pars interarticularis (spondylolysis) on both sides gives the scotty dog a collar and can cause spondylolisthesis (forward displacement of a vertebra, commonly L5)
What is the difference between disc bulging and disc herniation?
Disc bulging: no tear or rupture of the anulus fibrosus but the disc protrudes into the spinal canal
Disc herniation: nucleosus pulposus herniates through anulus fibrosus, resulting in pain and inflammation
If a patient presents with likely inflammatory lower back pain, what additional questions should you ask?
When is it worse?
Any buttock pain? (Seen in ankylosing spondylitis)
Does the pain wake them from sleep?
Any extra-articular manifestations (IBD can be associated with joint disorders, may get plantar fasciitis in ankylosing spondylitis, OA or reactive arthritis)
Why is it important to ask about how soon after a possible injury that pain developed?
Acute onset may indicate fracture, acute disc injury or a muscular cause (although note that muscle pain can take 24 hrs to develop)
Mr Mohamed, 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box; pain is in the centre of his lumbar spine and radiates to both buttocks but not legs
Pain worse on standing and walking but better lying down; rated 5/10 at rest and 8/10 with movement
Paracetamol not helpful
Mechanical or inflammatory pain? What extra feature is important to elicit?
Sounds mechanical
Good to know if the patient is hyper-mobile (any Hx of previous injury, evidence of joint laxity O/E)
Mr Mohamed, 25 year old refugee from Iraq, presents with 2/7 of lumbar back pain after lifting a heavy box
What other information would you like?
PHx of LBP (may indicate early wear and tear, possibility of spondyloarthropathies)
Site, radiation, mechanical pattern of pain
How soon after the precipitating event did the pain start?
Other medical Hx: use of oral steroids (e.g. for asthma), IVDU, immunosuppression
Neurological Sx
Mr Mohamed, 25 year old refugee from Iraq (arrived 3 years ago), presents with 2/7 of lumbar back pain after lifting a heavy box; pain is in the centre of his lumbar spine and radiates to both buttocks but not legs
Pain worse on standing and walking but better lying down; rated 5/10 at rest and 8/10 with movement
Paracetamol not helpful
No PHx of back pain
Smoker 5-10 cigarettes/day (especially relevant in older age group, as lung cancer commonly metastasises to bone)
SHx: married with 2 children
O/E: BP 115/70, HR 72, temp 37.2, slight loss of lumbar lordosis but no scoliosis, exquisite tenderness in mid-paravertebral lumbar spine, reduction of all back movements, no abnormal neurological signs
What do these examination findings suggest about the diagnosis? Further Ix? In what circumstances would you order prompt imaging?
Mx?
Less likely to be infective or inflammatory (no fever)
Likely acute muscle spasm, indicated by tenderness and reduction of ROM in all planes
Ix: probably not necessary (acute back pain is usually self-limiting) but consider XR if persistent pain
Prompt imaging if neurological or inflammatory/infective Sx
Mx: ongoing activity and heat pillow, provide written materail about acute back pain, consider need for paracetamol, NSAIDs and physio referral if pain does not resolve
Mx of acute lower back pain
Stay active: small beneficial effect on pain, rate of recovery and function compared to bed rest, reduces sick leave
Heat wrap therapy: continuous low level heat wrap therapy in first 48 hrs reduces pain, stiffness and disability over the next 3-4 days (better than paracetamol, NSAIDs or placebo, but not routinely available in Aus)
Patient information: should be “activity-focussed”
NSAIDs: given in practice but conflicting evidence for their use and efficacy
Muscle relaxants and spinal manipulation NOT recommended (conflicting evidence of benefit, risk of AEs)
Mechanism of NSAIDs
COX 1 and 2 inhibition (unless selective)
What is the risk with use of selective COX-2 inhibitors (e.g. celecoxib)? Possible mechanism? When are they recommended?
Increased risk of MI so CI in those with significant CV RFs
May be due to pushing AA through to TA2 production, increasing platelet aggregation
Recommended with PHx of bleeding ulcer in absence of other RFs
What types of pain should be considered when asking about radiation of lower back pain?
Referred pain: MSK, visceral
Radicular pain: nerve root irritation
What is the relationship between ankylosing spondylitis and pulmonary function?
Restrictive lung disease may occur in patients in later stages, with costovertebral and costosternal involvement limiting chest expansion
