Primary care - Spinal Disorders Flashcards
`Which infl condo usually presents as pain in distal limbs
PMR
Treatment of PMR
Prednisolone
People most affected by PMR
Women over 50
2 drugs causing SLE
Carbamazepine
Hydralazine
Which hormone is related to SLE
Oestrogen
Drugs for treating Raynaud’s
Iloprost
Sidenifil
Ca channel blockers
Most common prevention of ALPS
Vascular thrombosis - DVT/PE
Recurrent miscarriages
Strokes in those under 45
Dx test for APLS
Anti-cardolipin antibodies
Treatment of scleroderma
BP management
PPI
Vasodilators
Exercise
Managed abx
Broad spectrum e.g. co-amoxiclav, quinolone, cephalosporins
When can you use managed abx
When pts are allergic to other abx or when drugs are restsnat
Treatment of 59 yo man w chest infection
Amoxiccilin 500mg TDS
Clarithromycin 250-500mg BDS
Treatment of 30 yo man w MBP
NSAIDs and paracetamol
Rest
Muscle relaxant - diazepam
Concerns about diazepam
Can be addictive - valium
Treatment of 49 yo woman w/ acid reflux
PPI e.f. omeprazole or lansoprazole
If n to getting better could be H. Pylori infection - treat with PPI and 2 anti-bacterials
Treatment of 3 yo with impetigo
Flucloxacillin 125-500mg QDS 5-7days
Topical fusidic acid
Treatment of 7 yo with bacterial sore throat
Penicillin V
Ddx of back pain - trauma
Whiplash
Fracture
Other muscular strains
Ddx of back pain - cancer
Myeloma
Bone secondaries
Ddx of back pain - structural/degerative
Spondylosis
Spondylolisthesis
Gross scoliosis/ kyphosis
Spondylosis
Spinal OA with osteophyte formation and disc degeneration
Ddx of back pain - metabolic
Osteoporosis with vertebral collapse
Osteomalacia
Paget’s
Ddx of back pain - infections
Shingles
Discitis
Osteomyelitis – bacterial/TB
Epidural abscess
Ddx of back pain - infl
Ankylosing spondylitis
PMR
Coccodynia
Ddx of back pain - referred pain
Hip Abdo Kidney/Bladder Ovary Pelvis
Yellow flags
Belief that pain and activity is harmful Sickness behaviours Social withdrawal Emotional problems Problems/dissatisfaction at work Overprotective family Inappropriate expectations of treatment
Common symptoms seen with prolapsed discs
Radicular pain due to spinal nerve root compression
Shooting, sharp pain
Usually unilateral
Localised pain due to prolapsing itself
Limited lifting of spine (straight-leg test)
Signs of severe prolapsed dose which requires urgent referral
Drop foot and affected motor function
Therapeutics for prolapsed disc
Neuropathic pain doesn’t always respond to typical analgesia so given gabapentin or amitriptyline
Clinical features of spinal stenosis
Causes bilateral buttock and leg pain
Paraesthesia
Numbness in legs when walking
Relieving factors for spinal stenosis
Rest
Leaning forward - widens spinal canal
Ix for spinal stenosis
MRI
Treatment for spinals the noses
Spinal decompression
Refer immediately
Types of laxatives
Bulk laxatives - draw water in
Stimulant laxatives - causes bowels to contract
Common laxatives
Senna
Lactulose
Macrogol
Why is colchicine only used for acute flares of gout
Fairly toxic is max 12 tablets
QDS 3 days or BDS 6 days
Ramipril
ACE inhibitor
Anti-hypertensive
Can give pts irritating cough
Causes of atherosclerosis
Smoking
High cholesterol
Q risk
Risk of having heart attack in 1o years
When should pt be advised to lower cholesterol
If Q score is above 10
Femoral artery blockage presentation
Pain
Numbness
Cold
Reduced sensation
Surgical emergency
Causes of cauda equina syndrome
Compression of the spinal cord and the nerves/nerve roots arising from the cauda equina
Most common cause of CES
Prolapsed IVD
Risk factors for CES
Older Age High Impact Sports Being Overweight or Obese Manual Job/Labour Genetic Predisposition for Prolapsed Disc Previous Severe Back Injury
Ddx for CES
Radiculopathy – presents with radiating back pain but no faecal, urinary, or sexual dysfunction.
Cord compression – a surgical emergency similar to CES but is characterised by upper motor neurone signs.
Mx of CES
Lumbar decompression surgery (laminectomy or discectomy) must be done quickly to prevent permanent damage e.g. paralysis of the legs, loss of bladder and bowel control, sexual function, or other problems
Prognosis of CES
Variable depending on the cause, patient factors and the time from symptom onset to surgery.
Even with treatment, around 20% of patients do not regain full function
May require catheter or physio/ot
Epidemiology of radiculopathies
Most common in 50+
More men affected than women
Symptoms associated with radiculopathies
General weakness
Radiating pain (i.e. compression of a nerve in the cervical spinal area may cause issues within the forearm)
Lack of control within the specific muscle
Potential numbness
Paraesthesia
Ix for radiculopathies
Full examination
MRI
Electromyography to examine how the muscles are functioning - by comparing them at rest and during contraction
Mx for radiculopathies
Most are self - limiting
PT
NSAIDs/ steroids
Surgery in extreme cases
NSAIDs for OA
Treatment for up to 12 weeks Etoricoxib 60mg Diclofenac 150mg Ibuprofen 2400 mg Naproxen 1000 mg
NSAIDs for AxSpa
Treatment for up to 6 weeks
Non selective NSAIDs
Coxibs
NSAIDs for rotator cuff tendinopathy
Non-selective for up to 4 weeks
Adverse events for NSAIDs
GI adverse events
Myocardial infarction
Stroke
Heart failure
What does testing reflexes allow
Lower and upper motor neurone lesions to be distinguished reliably
When is reflex testing essential
If you suspect spinal cord and cauda equine compression, acute cervical or lumbar disc compression
Reflexes in arms
Biceps - C5/6 myotome
Brachioradialis - C6 myotome
Triceps - C7/8 myotome
Reflexes in legs
Knee - L3/4 myotome
Ankle - S1/2 myotome
Explaining process of testing reflexes to pt
Reflexes in the arms, legs and jaw will be tapped
This will be painless
They shouldn’t be alarmed if their limbs jerk nor concerned if they don’t
Interpreting reflex testing
Absent jerk points to lower motor neurons lesion
Very brisk reflection suggest an upper motor lesion
Sciatica
Clinical dx based on symptoms of radiating pain in one leg with or without associated neurological deficits on examinations
What is sciatica caused by
Infl or compression of the lumbosacral nerve roots (L4 - 5) forming sciatic nerve usually by disc herniation or rarely trauma
Mx of sciatica
Most pt’s improve over time with conservative treatment incl exercise, manual therapy and pain management
Imaging for sciatica
Imaging only requested if pain persists for 12+ weeks or the pt develops progressive neurological deficits
Symptoms of sciatica
Unilateral leg pain more severe than low back pain
Pain most commonly radiating posteriorly at the leg and below the knee
Numbness and/or paresthesia in the involved lower leg
+ve neural tension test (straight leg/ femoral nerve)
Muscle weakness/ absence of tendon reflexes/ sensory deficit
Prognosis of sciatica
Most people experience an improvement in symptoms over times with either conservative treatment or surgery
Low back pain radiating to leg indicator of poor prognosis - increased pain, disability and poor QoL
Examples of manual therapy
Spinal mobilisation
Red flags for referral - sciatica
Severe or progressive neurological deficits
Suspicion of cauda equina syndrome with signs of urinary retention and/or decreased anal sphincter tone
Suspicion of cancer or infection
Hx of trauma
Persistent sciatica for 12 weeks from onset of symptoms despite conservative care
