Orthopedics Flashcards
What is non specific low back pain?
Tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg
What is radicular pain?
Pain caused by irritation or compression of nerve roots
Typically pain/numbness in a dermatomal distribution
Describe the epidemiology of low back pain
Annual incidence of first episode: 6%-15%
Annual incidence of any episode: 1% - 36%
Lifetime prevalence: Estimates up to 84%
Name some specific causes of low back pain
Infection Fracture Malignancy Inflammatory disorders: ankylosing spondylitis Cauda equina compression Non-spinal causes of back pain
How common is infection as a cause of low back pain? And how would you go about diagnosing it?
Account for
Where is the lower back?
Area bounded by the bottom of the 12th ribs, the buttock creases and the mid-axillary line
What investigations would you do in a patient that you suspected had an infective cause for their lower back pain?
Imaging, blood count, inflammatory markers
In whom are osteoporotic fractures a more likely cause of their lower back pain?
Older people, female, low body mass, taking glucocorticoids, past history of fragility fracture, Cushing’s syndrome, alcohol intake, smoking, regular falls
How do you diagnose osteoporosis?
Measure bone mineral density using a DEXA scan
Normal: t score >-1
Osteopenia: >-2.5
Osteoporosis:
What is the specific treatment for osteoporosis? What is the mechanism of action?
Bisphosphonates: encourage osteoclasts to undergo apoptosis so reducing bone resorption
Examples: alendronate, risendronate, zoledronic acid
What are the most common malignancies which may present as lower back pain?
Primary: Myeloma, Intra-abdominal disease
Metastatic disease: Breast, Prostate, Lung
What malignant cause of back pain do you suspect in a patient who presents with >60, back pain, weight loss + other abdominal symptom or new onset diabetes?
Pancreatic cancer
What malignancy might you suspect in a patient who presents as >60 with persistent back pain?
Multiple myeloma
What investigations would you do for a patient who you suspect has multiple myeloma?
Bloods; FBC, Calcium, Plasma viscosity/ESR
What investigation would you do for a patient with suspected pancreatic cancer as a cause of their back pain?
Urgent direct access CT
What are the nice guidelines on patients with cancer with back pain in whom you should act urgently (
Pain in the thoracic or cervical spine Progressive lumbar spinal pain Severe unremitting lower spinal pain Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) Localised spinal tenderness Nocturnal spinal pain preventing sleep
How does Ankylosing spondylitis typically present?
Young men
Gradual onset
Relieved by exercise
Morning stiffness
What are extra articular symptoms of Ankylosing spondylitis?
Uveitis: inflammation of uvea, pigmented layer between inner retina and outer fibrous layer of sclera and cornea
Enthesitis: inflammation of the entheses, sites where tendons or ligaments insert into bone
What might you see on an X-ray of an Ankylosing spondylitis spine?
Bamboo spine: vertebral body fusion by marginal syndesmophytes
Typically involves thoracolumbar and/or lumbosacral junctions and predisposes to unstable vertebral fractures
Outer fibres of annulus fibrosis of IV discs ossify which results in the formation of the syndesmophytes between adjoining vertebral bodies
What is inflammatory back pain?
Chronic back pain >3 months Onset of symptoms before age 45 yrs Back pain at night Morning stiffness (>30 mins) Improvement with exercise
When should you consider Ankylosing spondylitis as opposed to inflammatory back pain?
If several factors present together: Inflammatory back pain Alternating buttock pain Response to NSAIDs Onset of symptoms before age 45 Peripheral disease manifestations (arthritis, dactylitis, enthesitis) Confirmed acute anterior uveitis Positive family history HLA-B27 positive Sacroiliitis/spondylitis by imaging
What is cauda equina syndrome and what key symptoms would you ask a patient about?
Compression of nerve roots below level of spinal cord termination: caused by central disc prolapse, tumour
Weakness / numbness in legs
Bowel or bladder dysfunction
Saddle / perineal anaesthesia
What is the nice guidance on suspected cauda equina
compression in people with cancer?
Immediate referral metastatic spinal cord compression co-ordinator if: neurological symptoms including radicular pain,
any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
Name some non spinal causes of low back pain
Abdominal aortic aneurysm Pancreatitis / pancreatic cancer Renal pain (stone/infection) Peptic ulcer Gynaecological disorders: fibroids Shingles
List some red flags which you want to ask about in a patient presenting with lower back pain
Age >50 Bladder dysfunction Cancer history Immune suppression Rest/night pain Trauma Saddle anaesthesia Lower extremity neurological deficit Weight loss Recent infection Fever/chills
What is Lasègue’s sign?
Straight leg raise: determine whether patient with low back pain has a herniated disk, often at L5
Patient experiences sciatic pain when straight leg raised between 30 and 70 degrees
What is Kernig test?
Thigh flexed at the hip, knee at 90 degrees
Subsequent extension in knee is painful and often resisted
May indicate sub arachnoid haemorrhage or meningitis
What is bragards test?
Used to determine whether a source of lower back pain is nervous or muscular
Straight leg raise is done, if positive, leg lowered just below point of pain and then ankle is dorsiflexed
If pain increases, pain is likely nervous in origin
If no increase in pain, source is likely muscular
When is imaging of spine needed for low back pain?
Investigation for specific cause of back pain: Metastatic Disease, Bloods may be more appropriate and easier to organise
When surgery is being considered: Suspected cauda equina compression - Immediate, Radicular pain that is not resolving, To identify those with operable lesions congruent with symptoms, Selected patients who might be considered for spinal fusion
What is non specific low back pain?
Tension, soreness and/or stiffness in lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg
What different durations of back pain might present?
Acute: 3 months: Prevalent cases, Major health burden
Describe the management of acute low back pain
Exclude serious causes of back pain: Ask about micturition
Avoid bed rest
Encourage activity
Adequate analgesia: Paracetamol, NSAIDs, mild opioids, Muscle relaxants if indicated
Specific treatment not required: No evidence of effectiveness
What do you do to manage sub acute Radicular pain?
Consider imaging or surgical opinion: Test clinically for nerve root compression, Sensitive but not specific
Delayed surgery less likely to reduce any neurological deficit: Many still improve without surgery, Remember risks of surgery
Describe the care pathway for persistent low back pain which goes on for more than 12 months
GP advice and analgesia, if no improvement then choice of acupuncture, exercise or manual therapy
If continuing problems, try one or more further course of treatment
If continuing pain and disability, then combined physical and psychological therapy of 100 contact hours
If continuing pain and disability, consider surgical referral
What choice of physical therapies are available to treat back pain?
Acupuncture: up to a maximum of 10 sessions over a period of up to 12 weeks
Exercise: up to a maximum of eight sessions over a period of up to 12 weeks, aerobic activity, movement instruction, muscle strengthening, postural control, stretching
Manual Therapy: up to a maximum of nine sessions over a period of up to 12 weeks
What are problems with chronic non-specific low back pain?
90% of costs, Vast majority of health care usage Unlikely to ever get better Major impact on quality of life (DALYs) Variable course Treatment only modest benefit
What factors indicate a poor prognosis in a patient with chronic low back pain?
Widespread pain, severity, duration, previous episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction
What are Patient expectations for treatment of back pain?
Clear diagnosis Pain relief Physical examination Confirmation that pain is real Confidence based association: understanding, listening, respect, and shared decision making
What factors concern patients most at a pain clinic?
Spoiled identity: more important than pain or disability
Unmet expectations: GP don’t take their pain seriously, appear not to care
Making sense of pain: doctors don’t help them make sense of pain; just provide a medical interpretation
The future: acceptance / accommodation
Describe the fear avoidance model in regards to pain
Pain experience leads to fear of pain, which leads to avoidance of the activity, which then leads to disuse, disability and depression, this then exacerbates the pain experience
The way for patients to avoid this cycle is that they don’t experience fear about their pain, so they confront it and therefore more likely to recover
What acute treatments are available for back pain?
Pain killers: Paracetamol, NSAIDs (Oral, Topical), Opioids (Weak, Strong) Muscle relaxants (acute pain only): Benzodiazepines (diazepam)
What opioids can be used to treat back pain?
Weak opioids: Codeine, Dihydrocodeine
Strong opioids: Morphine, Buprenorphine, Tramadol (some consider to be weak), Oxycodone, Fentanyl (patches)
