Tutorial 2 - Main musculoskeletal conditions presenting to GP: Flashcards
Name common reasons for back pain presenting to general practice.
- Pulled muscle / strain
- slipped disc / Sciatica / cauda equina syndrome
- Ankylosing spondylitis
- Osteoporosis / broken bone
-Vertebral tumour
-Vertebral osteomyelitis (infection)
What is a slipped disc and what can it cause ?
- Slipped disc is when part of the intervertebral discs herniate out.
- When they herniate out they can apply pressure on nerve roots.
- One condition not to miss would be sciatica - pinching of the sciatic nerve.
- Red flag condition - caudal equina syndrome.
What is sciatica ?
- Sciatica is compression of the lumbosacral nerve roots (L4 - S1) which form the sciatic nerve.
Name 4 symptoms of sciatica.
- Saddle anaesthesia
- Urinary / bladder dysfunction ( often urinary retention )
- Sharp / burning pain in lower back, buttocks, posterior thigh, calves.
- Weakness in myotome distribution.
Name 4 risk factors for sciatica.
- Old age ( degenerative changes )
- Obesity
- Smoking
- Occupational i.e. heavy lifting regularly.
What investigations can you order to confirm a sciatica diagnosis ?
MRI.
How do you diagnose sciatica ?
- Presence of symptoms (pain, weakness ,anaesthesia , urinary dysfunction)
- Conduct a spinal examination ( with special tests )
- Imaging i.e. MRI
What is the management for sciatica ?
- Reassure patient that symptoms of sciatica should go within 4 - 6 weeks.
- Urge patient to continue remaining as active as possible.
- Offer analgesics such as paracetamol / ibuprofen.
- If appropriate NSAIDS / opioids ( but explain risks of long term use ).
- Offer physiotherapist ( NHS waiting times can be long, so maybe prompt for a private one )
- If pain does not resolve / progresses can be admitted for surgery.
What is cauda equina syndrome ?
- The caudal equina is a bundle of nerves travelling from the Lower back region to supply the lower limbs and pelvic organs.
- Thus, caudal equina syndrome is the compression of all of these nerves.
What are the symptoms of caudal equina syndrome ?
- Bilateral sciatica
- Progressive weakness in knee flexion, foot eversion, dorsi flexion etc.
- Difficulty initiating micturition
- Loss of sensation of rectal fullness
- saddle anaesthesia
- Erectile dysfunction
What is the management for cauda equina syndrome ?
- Refer onto hospital for urgent decompression ASAP.
- Surgery within 8 hours of onset of symptoms has a good prognosis.
- If left can have permanent urinary / bladder dysfunction.
What is ankylosing spondylitis ?
- Chronic inflammatory condition.
- Results in inflammation / fusion/ stiffness of vertebral joints - especially the sacro - iliac joint.
-Inflammation can also progress to other parts of body such as the eyes / blood vessels etc.
How does ankylosing spondylitis present ?
- Chronic back pain / stiffness that improves with activity.
- Dactylitis ( swelling of a toe / finger)
- Fatigue
- Enteritis ( inflammation of GI tract )
- Arthiritis ( predominantly lower limb )
What are some risk factors for ankylosing spondylitis ?
- Autoimmune condition - presence of HLA - B27 gene.
- Men > female
- Presents early adulthood / late adolescents
What are the investigations for ankylosing spondylitis ?
- Difficult to diagnose BUT
- Blood test for inflammation
- genetic test for HLA - B27 gene
- MRI / X - RAY scans
What is the management for ankylosing spondylitis ?
- Exercise
- Physiotherapy ( slow bone fusion / stiffness )
- Medication ( NSAIDS - ibuprofen , paracetamol, opioid - codeine, anti TNF therapy, monoclonal antibodies, corticosteroids, DMARDS.
- Surgery
How does vertebral bone cancer present ?
- Pain at the site of the tumour
- Back pain which radiates to other parts of the body, and is worse at night
- Loss of sensation to temperature and pain
- Loss of bowel / bladder control
Which cancers often metastasise to the vertebrae ?
- Lung
- Prostate
- Breast
What investigations can be done for vertebral cancer ?
- Biopsy
- MRI scan
What investigations can be done for vertebral cancer ?
- Biopsy
- MRI scan
What is the management for vertebral tumour ?
- Monitoring - if benign and growing at a slow speed
- Surgery
- Radiation therapy
What is osteoporosis ?
- Osteoporosis is a disease categorised by a low bone mass index and progressive deterioration of bone tissue - making fractures more likely.
How would osteoporosis present ?
- Back pain
- Fracture easy
- Stooped posture / loss of height
Name some risk factors for osteoporosis.
- Female sex
- Menopause
- Ageing
- Vitamin D / calcium deficiency
- Smoking
- Use of oral corticosteroids
What is a BMD and T score ?
- Bone mineral density
- Duel energy x - ray test
- Reports back a T score
- T score between 0 and -1 is normal, T score from -1 to -2.49 considered as osteopenia and below -2.5 considered as osteoporosis.
What is the management for osteoporosis ?
- Bisphosphonates ( oral or injection ) i.e. alendronic acid
- Calcium / vitamin D supplements
- HRT / testosterone
What is vertebral osteomyelitis ?
- Painful vertebrae infection
- Staph aureus infection.
How does vertebral osteomyelitis present ?
- Back pain that does not get better with movement / pain relief.
- Weight loss
- Weakness
What are some risk factors for vertebral osteomyelitis ?
- Dialysis
- Inject drugs using unclean needles ( recreational drugs ? )
- Immunocompromised state
What investigations should be ordered for suspected vertebral osteomyelitis ?
- FBC
- CRP
- Blood / fluid / pus culture
- Biopsy
- Imaging - MRi scan
How is vertebral osteomyelitis treated ?
- Antibiotic course for infection.
How is vertebral osteomyelitis treated ?
- Antibiotic course for infection.
What is osteoarthritis ?
- Osteoarthiritis is a type of arthiritis
- It involves the wear and tear of the synovial joints
- Leading ultimately to bone on bone rubbing, which causes pain.
How would osteoarthritis present ?
- Pain / swelling - improves with rest
- Morning stiffness < 30 mins
- Grating / crackling sensation
- Bone spurs
What are the risk factors for osteoarthritis ?
- Family history
- Females
- Obesity
- Increasing age
- Trauma ( occupational / injury etc ).
What investigations can be carried out for osteoarthritis ?
- Lab tests ( blood test - rule out rheumatoid, joint fluid analysis - rule out infection / gout )
- X - ray
What would XRAY of osteoarthritis show ?
- LOSS:
- Loss of joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
What is the management for osteoarthritis ?
- Self management advice i.e. lose weight if needed
- Offer psychosocial help for depression / anxiety
- Analgesics i.e. NSAIDS - ibuprofen, opioids - codeine.
- Joint replacement surgery.
What is inflammatory arthiritis ?
- Ankylosing spondylitis
- Rheumatoid arthirtis
- Gout
- Psorotic arthiritis
What is rheumatoid arthiritis ?
- Autoimmune condition
- Body attacks synovial joints
- Later on in disease can present with signs of systemic inflammation.
What are the symptoms of rheumatoid arthiritis ?
- pain / stiffness - symmetrical
- Commonly affects small joints in hands and feet
- Swollen
- Morning Stiffness lasts longer than 30 mins
- Pain better with use
What are the risk factors for rheumatoid arthiritis ?
- Increasing age
- Female gender
- Family history
- Smoking
What investigations can be done for suspected rheumatoid arthiritis ?
- Rheumatoid factor (rF)
- Anti CCP
- X - ray
What would X-ray of rheumatoid arthiritis look like ?
- Loss of joint space
- Osteoporosis
- Peri - articular erosions
- Subluxation
What is the treatment of rheumatoid arthiritis ?
- Medical therapy - DMARDS, Anti TNF therapy, Monoclonal antibodies
- Analgesia
- Physiotherapy
- Surgery - joint replacement
What is gout ?
- Gout is a type of inflammatory arthiritis
- Often due to rate crystals forming inside and around joints secondary to hyperuricemia.
How does gout present ?
- Intense joint pain
- Lingering discomfort
- Red / swollen / tender joint
- Limited range of motion
Name some risk factors for gout.
- Diet - alcohol, red meats
- Obese - body produces more uric acid
- Medication - i.e. ACEI can increase uric acid levels
- men and women (after menopause)
- Family history
What investigations can be done if gout is suspected ?
- Joint fluid test - presence of crystals
- Blood test - level of uric acid
- Xray
- Dual energy CT scan ( visualise crystals )
What is the management for gout ?
- NSAIDS / corticosteroids - control pain
- Allopurinol - control levels of uric acid in body
- Exercise
- Diet - limit foods high in purines such as mussels and alcohol.
