Seminar H - Back Pain Flashcards
Common Conditions 0-15
Osteochondritis, Scoliosis
Common Conditions 15-30
Prolapsed intervertebral disc Trauma Fractures Ankylosing spondylitis Spondylolisthesis Pregnancy
Common Conditions 30-50
Prolapsed intervertebral disc
Carcinoma (lung, breast, prostate, thyroid and kidney)
Degenerative disease
Common Conditions 50 yrs +
Degenerative Osteoporosis Paget’s disease Carcinoma Myeloma
Spondylosis → Definitions
Intervertebral dis generation, instability osteoarthritis (OA) of the facets joints within any part of the spine but more commonly the cervical and lumbar regions.
Cervical region → cervical spondylosis
Spondylosis → Intervertebral dis generation is a
Normal, active, age related process involving both genetic, biomechanical and environmental factors which cause disruption of the chemical constituents of the cartilaginous annulus fibrosis and inner gel like nucleus pulposus
Spondylosis → Resulting process
Micro tears in the AF, escape of the NP a decreased disc space, reduced shock absorption and flexibility.
The vertebra and the synovial joints then develop compensatory degenerative changes typical of the changes of osteoarthritis namely osteophytes, loss of joint space, subchondral sclerosis and subchondral cysts3.
Spondylosis → Presentation
Chronic and intermittent back pain typically following physical activity, which is progressive and is often associated with acute exacerbations and diminished spinal mobility, stiffness and muscles spaces.
Spondylosis → Sondylosis knock on effects leading to
Simple Low Back Pain
Nerve root compressions
→ Intervetebral disc prolapse
Development of spinal stenosis
Sondylolithesis
Neurological features of nerve root irritiaion results because
Impingement by the prolapses disc, inflamed synovial joints of degenreat efacet joints and the osteophytes that result from the osteoarthritis of the facet joint degeneration
Xray presentaion
- Disc space narrowing
- Sclerosis
- Deformity
- Marginal osteophytes
Treatment
Simple analgesics NSAIDS Corsets for support MDT Surgery (Severe cases – spinal fusions and spinal decompression)
Simple Low Back Pain → implies no nerve root irritation or serious spinal injury.
Characterised by
- Onset 20-55 yrs
- Presence of lumbrosacral, buttock and thing pain
- Mechanical in nature, varying with physical activity anf with time
- Patient is otherwise well with no systemic features
- Clinical features resolve within six weeks
- Pain may persist or relapse over time
Simple Low Back Pain → implies no nerve root irritation or serious spinal injury.Xray (not usually needed) may show
Simple degenerate change or OA
Osteoarthritis X-Ray features →
- Traction spurs
- Spondyliolisthesis
- Disc space narrowing
Facet joint OA that is characterised by →
- Joint space narrowing
- Subchondral sclerosis
- Osteophytes
- Subchondral cysts
- Root canal stenosis
Nerve Root Pain Presents with usually
with leg pain rather than back pain. It is often helpful to ask the % of back pain versus leg pain when eliciting the symptoms from the patient. The pain is often in a nerve root distribution.
Nerve Root Pain Symptoms characterised by
- Unilateral leg pain which is worse than low back pain.
- Pain which radiates to the calf foot or toes.
- Numbness and paraesthesia present in the same direction.
- Clinical signs of nerve root irritation
- Straight leg raise reproduces leg pain below knee
- Bow String sign
- Lasegue’s sign
- Cross leg pain
- Localised neurological signs Power/Reflexes/Sensory loss
Serious Spinal Pathology → characterized by
- Onset in individuals who are aged less than 20 or greater than 55 years.
- Constant, progressive, unrelenting, non-mechanical pain.
- Thoracic pain.
- A past medical history of carcinoma.
- Drug misuse, steroid therapy, HIV.
- Violent trauma in the young e.g. an RTA . Trauma in the elderly osteoporosis.
- Constitutional features - fever, fatigue, malaise and weight loss.
- The presence of neurological features.
- Structural deformity.
- Severe persistent restriction of lumbar flexion.
Intervertebral Disc Prolapse →Definition
Very simply, each intervertebral disc, which is located between each vertebra, is composed of an outer ring of cartilaginous annulus fibrosis (red arrow) and an inner centre of gelatinous nucleus pulposus (green Arrow).
When an intervertebral disc prolapses, as has occurred in the adjacent diagram, the central nucleus pulposus is forced or extruded posterolaterally causing the annulus fibrosis to bulge, a complete prolapse occurs when the nucleus pulposus extends beyond the annulus fibrosis.
Intervertebral Disc Prolapse → Clinical features produced when
Extrusion impinges on the spinal nerve roots and spinal cord.
Severity and pattern of the symptoms and signs depend on the site of the prolapsed intervertebral disc.
Intervertebral Disc Prolapse →Note:
No correlation between the size of prolapse and the symptoms which appear to be related to the amount of inflammation involving the dorsal root ganglion of the compromised nerve root
Intervertebral Disc Prolapse → Clinical features
- A sudden or insidious onset of severe low back pain
- Muscle spasm
- Localised tenderness
- Diminished lumbar spinal movements A visible scoliosis.
Intervertebral Disc Prolapse → Clinical features typically occur during
- An episode of coughing
- Lifting
- Sneezing
- Twisting in which there is a recent history of trauma, back strain or injury.
Intervertebral Disc Prolapse → If there is nerve root involvement
- Severe unilateral shooting pains will radiate to buttocks, thigh or calf
- In association with paraesthesia
- Numbness
- Other neurological signs
Osteomyelitis Definition
As an infection of bone, but more specifically vertebral osteomyelitis, when the vertebral bodies become infected, can occur.
Osteomyelitis Common infecting organism in the UK is
Staphylococcus aureus followed by E. coli, Pseudomonas and Proteus.
Osteomyelitis Routes of bacterial spread
Direct or haematogenous (via the venous plexus of Batson).
Osteomyelitis Method of diagnosis
MRI
Osteomyelitis Pathologically
Is an infection with a subsequent inflammatory response, abscess formation (like the tuberculous “Potts abscess”), ischaemia and hence bone death (sequestrum). New bone can also occur (involucrum) as can the development of sinuses (cloacae) in severe disease which then discharge pus.
Osteomyelitis Presentation of pathology
This can present as a swelling in the groin from a psoas abscess.
Osteomyelitis Pain caused diminished by
Movement and muscle spasms
Osteomyelitis Signs of
Systemic infection Fever Malaise Fatigue Raised WCC ESR
Osteomyelitis Examination shows
Dramatic loss of range of movement
Local tenderness
Deformity such as gibbus from TB
Osteomyelitis Xray findings for osteomyelitis
Plain Radiographic Changes in Vertebral Osteomyelitis
No changes visible for the first few weeks.
Then evidence of intervertebral disc space narrowing and loss of disc height.
Localised osteopaenia.
Sclerosis.
Reactive new bone formation.
Soft tissue swelling and a paravertebral mass.
Later development of vertebral collapse and kyphosis. (Gibbus)
Osteomyelitis Special investigations
Blood tests Blood cultures Biopsy Radioisotope bone scanning MRI
Treatment for osteomyeltisi
Bed rests
Analgesics
IV antibiotics for six weeks (triple therapy for TB) the oral antibiotics
Occasionally surgical removal of dead bone
Drainage of abscesses
Cauda Equina syndrome → Definition
is a surgical emergency, requiring immediate referral. It is a rare condition in which the cauda equina component of the spinal cord, located below the level of L2, becomes compressed
Cauda Equina syndrome → Responsible for producing
- Sphincter disturbance leading to bladder or bowel dysfunction (either incontinence or retention)
- Gait disturbance
- Saddle anaesthesia
- Bilateral lower limb weakness if untreated or missed
- Sexual dysfunction
- Muscular pain
- Numbness
- Paraesthesia
Cauda Equina syndrome → Note
Ask the patient if they can distinguish the difference between motion and wind
Metastatic Bone Disease → Originating from carcinomas of the
Breast Bronchus Prostate Kidney Thyroid
Metastatic Bone Disease → Common site
Vertebral bodies in thoracic and lumbar spine
Metastatic Bone Disease → Spread is
Haematogenous
Metastatic Bone Disease → Back pain presentation
Persistent, severe and at night
Metastatic Bone Disease → Presenting features
Swellings
Hypercalcaemia and pathological fractures and features such as weight loss, fatigue and anaemia.
Metastatic Bone Disease → Investigations reveal
Elevate ESR and alkaline phosphatase and low haemoglobin
Metastatic Bone Disease → Late radiographs show
OSteolysis with bone destruction due to stimulation of osteoclasts
Metastatic Bone Disease → Other investigations
MRI
Radioisotopes
Metastatic Bone Disease → Primary lesion is prostate carcinoma
The radiograph can differ having osteoblastic deposits
Metastatic Bone Disease → Treatment
Curative or palliative using a combination of
1. Analgesia
2. NSAIDs
3. Radiotherapy
4. Hormonal therapy
5. Surgery
to make the patient as symptom free as possible.
Multiple Myeloma → PRIMARY Definition
Definition
(myeloma or plasma cell myeloma) is a disorder representing the accumulation of malignant plasma cells in the bone marrow resulting in the over production of immunoglobulin, predominantly monoclonal IgA, IgG and IgD (Bence-Jones protein a free monoclonal antibody of Kappa and gamma light chains).
Multiple Myeloma → PRIMARY Causes
Causes secondary hypocalcaemia, anaemia and renal damage if not managed early
Multiple Myeloma → PRIMARY Characterised by
Diffuse osteoporosis, usually in the pelvis, spine, ribs, and skull. The displacement of normal marrow causes a susceptibility to bacterial infection.
Multiple Myeloma → PRIMARY Patient predominance
Elderly men
African (slightly more)
Less in Asians(suggest genetic)
Multiple Myeloma → PRIMARY Exposure risks
Populations exposed to large amounts of radiation, such as survivors of the atomic disasters, have an increased risk for myeloma. Most individuals with multiple myeloma have no recognised predisposing pathologies. However, exposure to petroleum products, insecticides, herbicides, plastics, heavy metals, and asbestos appear to be weakly associated risk factors for the disease.
Multiple Myeloma → PRIMARYEffects
Bone destruction resulting in fractures and vertebral damage and hence back pain, recurrent infections, renal impairment and anaemia
Multiple Myeloma → PRIMARY Clinical Features
Bone pain Anaemia Renal Failure Infection Neurological symptoms
Multiple Myeloma → PRIMARYTreatment
Is an incurable progressive condition in which treatment aims to correct and slow the progression and includes chemotherapy, anticytokine therapy, with interferon alpha and interleukins, and supportive measures with bisphosphonates and erythropoietin.
yellow flags
→ The belief by patients that back pain is harmful and potentially severly disabling:
• The fear-avoidance behaviour in patients and hence reduced activity levels.
• The patients with a tendency to low mood and withdrawal from social interaction.
• The expectation by patients that passive treatments rather than a belief that active participation will help.
