Rheumatology Flashcards
Disc Prolapse
Age 40 male
Severe Lower Back Pain (LBP)
Spread into his buttock and Rt thigh
Relieved if lie down
Spinal stenosis due to osteophytes
Age 74 male
Backpain for last 2 yrs, lately worse
Refers to his buttock
Worse when he walks for a distance
Improve by sitting going down hill
Malignancy
Age 54 female
LBP for last 3/12, progressive worse
difficulty urinating and numbness in Rt leg
Absent knee reflex on the Rt
Semi-acute duration
Progressively worse
Some neurology
Do not miss/exclude
Inflammatory arthritis (Spondyloarthropathies)
Spinal Infection
Neoplasms
Fractures
Referred visceral pain
Red flags for lowerback pain
1)Neurological deficit
2)Trauma
3)Prev. surgery
4)Prolonged use of corticosteroids
5)Malignancy
6)Immunosuppression
7)Osteoporosis
8)Age onset < 20years
9)Inflammatory nature of pain
10)Unexplained fever/weight-loss
Mechanical lower back pain (causes)
-Nonspecific back pain (Muscle, tendon, ligament strain)
-Degenerative Disease (Spondylosis): Discs, Facet Joints
-Herniated Disc
-Spinal Stenosis
-Spondylolysis and Spondylolisthesis
-Fractures (Non- vs Osteoporotic)
-Severe kyphosis / scoliosis
MLBP Tx
- physical therapy to strengthen the back muscle
-some analgesia
-surgical intervention
Spondolysis
arthritis of the spine. Seen radiographically as disc space narrowing, osteophyte formation and arthritic changes of the facet joint.
- localized lumbar pain, but can refer downwards.
- Worse with standing or sitting, as well as with physical activity
- C-spine OA present with lateral neck pain, which do not refer below shoulders, worsen by lateral flexion or extension.
Herniated Disc
Acute onset
L4-L5/L5-S1 = 98%
Sharp, shooting, shock-like pain (often into legs)
Management often conservative initially
Typical Hx = pain in the center of the lower back with minimal radiation(if present locates to the buttocks or thighs), Deep dull ache pain, Improves = with standing, lying flat, reduce by extension. Worsen = with sitting, driving, lumbar flexion, bending, twisting, Valsalva maneuver, and coughing
Spinal Stenosis
Narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum
>60 yrs
Pain on extension (walking ,standing, going downhill, positional changes)
Relief (flexion) = Improved by rest, sitting, and lumbar flexion.
gluteal and lower extremity pain
fatigue that may or may not occur in conjunction with lower back pain
Spondylolysis & Spondylolisthesis
Fracture in pars interarticularis where the vertebral body and the posterior elements are joined. (L5)
Spondylolisthesis refers to the slipping forward of one vertebra on the next
When the defect in the pars interarticularis is not associated with a forward displacement, the term spondylolysis applies. LBP symptom, exacerbated by motion, lumber extension & twisting. Relieved extended rest. Progress to radicular pain into L5 distribution
Spondylolysis & Spondylolisthesis treatment
Bracing and rest are the cornerstones
Pain control and avoiding sports
Physical therapy should not be started until after an adequate rest period and once pain with daily activities has subsided: goals = Decrease extension stress of lumbar spine, strengthen elements that promote an anti-lordotic posture
slippage <50% + patient symptomatic = non-operative therapy (Stretching & strengthening exercises, anti-lodic brace, activity modification.)
Spina fusion (pain persists)
Cauda Equina Syndrome
Surgical emergency!
Typical Features:
Bladder / bowel dysfunction(urine retention + overflow)
Bilateral leg weakness/ numbness
Saddle sensory loss
Yellow flags - Chronicity
Beliefs that pain and activity is harmful
Emotional issues (depression / anxiety)
Work issues (dissatisfaction)
Compensation issues
History of LBP
Inflammatory Back Pain
pain/stiffness = >60min morning, improves during day
activity = improve symptoms
duration = chronic
age of onset = <40 years
Radio = sacroiliitis, spinal ankylosis, syndeamophytes
Inflammatory Back Pain (Features)
Plantar periostitis
Enthesitis
IBD
Uveitis
Psoriasis
ASAS/EULAR Recommendations for the Management of AS
Education, exercise, physical therapy, rehabilitation, patient associations, self help groups
NSAIDs
Axial /Peripheral disease, Analgesics
Surgery
Sulfasalazine
Local corticosteroids
TNF blockers
Golfer’s elbow
Medial Epichondilitis
inflamed, but the tendon insertions of the flexors of the forearm, which is why when he uses those muscles to flex his wrist, it aggravates the pain
part of Soft Tissue Rheumatisms
Soft Tissue Rheumatisms
pathology is in the ligaments, tendons and bursae surrounding a joint and not the joint itself
Clinical pattern recognition (Articular)
Deep diffuse pain
Active and passive painful
Joint swelling
Crepitation
Joint instability
Locking of the joint
Deformity
Clinical pattern recognition (Non- Articular)
Localized pain
Only Active painful
Point or local tenderness
Crepitation rare
physical findings are remote from joint capsule
