Week 12 - spinal disorders Flashcards
What is ankylosing spondylitis? (LO1)
Inflammatory arthritis of the sacroiliiac joints and axial skeleton characterised by ankylosing and enthesitis. This comes under a larger group of arthritis’ called seronegative spondyloarthropathies (SpA).
What is enthesitis? (LO1)
Inflammation at tendon insertions.
Describe the epidemiology of ankylosing spondylitis. (LO1)
- 0.1%-1% of the population.
- Varies with prevalence of the HLA-B27 and ethnicity.
- It is more prevalent in those with positive family history of spondyloarthropathy.
- Males are 3 times more likely to have it.
- 15-35 year olds.
- Symptoms will appear before the age of 45 in the majority of people.
Describe the pathophysiology of ankylosing spondylitis. (LO1)
- The result of interaction between environmental pathogens and the host immune system in genetically susceptible individuals.
- Increased faecal carriage of Klebsiella aerogenes has been reported in established AS.
- Increasing evidence that axSpA and AS are due to abnormal host response to intestinal microbiota and involvement of Th17 cells (cells with a key role in mucosal immunity).
- This reaction leads to the production of various inflammatory cytokines, e.g. IL-12, IL-23, IL-17 and TNF-α.
List the genes that increase susceptibility to ankylosing spondylitis. (LO1)
- HLA-B27: 95% of patients with ankylosing spondylitis are positive for this gene, an MHC class 1 molecule.
- ERAP-1: an endoplasmic reticulum protein which facilitates intracellular antigen processing and binds with its presenting MHC molecule, HLA-B27.
- IL-23 receptor.
- Molecules involved in directing Th17 cell responses, e.g. STAT13.
Describe the musculoskeletal presentation of ankylosing spondylitis. (LO1)
- Prolonged morning stiffness of insidious onset, lasting >3 months.
- Bilateral sacroiliac joint tenderness (sacroiliitis).
- Inflammatory back pain - IMPROVES WITH EXERCISE, WORSENS WITH REST.
- Limited lumbar spine motion.
- Tenderness at enthesis, especially Achilles’ tendons and plantar fascia.
- Rib cage involvement: limited chest expansion.
- Possible peripheral joint arthritis, usually involving lower extremities.
Describe the presentation of advanced ankylosing spondylitis. (LO1)
- Compensatory hyperextension of the neck.
- Fixed flexion of the hips.
- Compensatory flexion of the knees.
List the non-musculoskeletal manifestions of ankylosing spondylitis. (LO1)
- Iritis and uveitis.
- Aortic insufficiency.
- Cardiovascular disease.
- Pulmonary fibrosis.
- Increased risk of osteoporosis.
What two types of investigations can be carried out for ankylosing spondylitis? (LO1)
- Bloods.
- Radiological.
List the blood tests that can be done to investigate ankylosing spondylitis. (LO1)
- FBC.
- ESR.
- CRP.
- Serological rheumatoid factor.
- Genotyping for HLA-B27.
Describe the interpretation of blood results in a patient with ankylosing spondylitis. (LO1)
- FBC - showing anaemia of chronic disease.
- ESR - often elevated during active phases of the disease.
- CRP - often elevated during active phases of the disease.
- RF - negative.
- HLA-B27 genotyping - positive in 95% of patients with AS but not required for a diagnosis. May be useful where the clinician has doubts.
List the radiological investigations that can be done to investigate ankylosing spondylitis. (LO1)
- X-ray - can appear normal.
- MRI - first choice.
Describe the advantages of using MRIs to investigate ankylosing spondylitis over x-rays. (LO1)
- Able to detect inflammatory back disease in cases where x-rays appear normal.
- Prevents x-ray exposure to the pelvis which is particularly important in young patients.
Describe the potential results of MRIs in patients with ankylosing spondylitis. (LO1)
- Sacroiliitis and bone oedema highlight ongoing inflammation.
Despite MRIs being first choice for ankylosing spondylitis imaging, how can x-rays also be helpful? (LO1)
- They can help assess damage where substantial mechanical change has occurred.
- Views of the lumbar spine may show bamboo spine: squaring of vertebrae and formation of syndesmophytes (due to ossification of the longitudinal ligaments).
- At other sites: enthesitis erosions, e.g. at plantar fascia of Achilles’ tendon.
Describe the conservative management of ankylosing spondylitis. (LO1)
- Physiotherapy: long-term exercise programme with the aim of maintaining normal posture and exercise activity.
- Hydrotherapy - can be beneficial.
Describe the drug treatment side of management for ankylosing spondylitis. (LO1)
Initial treatment:
- NSAIDs.
Continuous therapy is needed where there is ongoing evidence of inflammation:
- NSAIDs.
- COX-1 inhibitors.
- COX-2 inhibitors.
Anti-TNFs:
- Secukinumab: anti-IL17.
- Good efficacy in treating and preventing ankylosing spondylitis progression.
When can DMARDs (methotrexate, sulphasalazine) be used for ankylosing spondylitis? (LO1)
- These immunosuppressive drugs are less beneficial in ankylosing spondylitis unless there is peripheral arthritis.
Describe the prognosis of ankylosing spondylitis. (LO1)
- Prognosis for any AxSpA disorder not fully understood yet.
- They can remain mild and/or episodic in many patients for many years.
- HLA-B27 positivity, persistently high CRP and high functional incapacity are markers of poor prognosis and markers of extension to ankylosing spondylitis (if not already developed).
What are two main classifications of back pain? (LO2)
- Inflammatory.
- Non-inflammatory.
List the possible causes of non-inflammatory back pain. (LO2)
- Mechanical/low back pain +/- sciatica.
- Osteoarthritis.
- Spinal stenosis.
- Spondylolisthesis.
- Scoliosis.
- Vertebral fracture.
List the possible causes of inflammatory back pain. (LO2)
- Infection, e.g., disciitis, osteomyelitis, abscess.
- Axial spondyloarthropathies.
- Malignancy.
List the terms commonly used when talking about back pain. (LO2)
- Discogenic pain.
- Degenerative disc disease.
- Lumbar disc herniation.
- Secondary to lumbar degenerative disease.
- Facet joint pain.
List some alternative terms for sciatica. (LO2)
- Sciatica/lumbago.
- Radicular pain/radiculopathy.
- Pain radiating to the leg.
- Nerve root compression/irritation.
- Neurogenic claudication.
- Spinal stenosis.
Describe the epidemiology of mechanical back pain. (LO2)
- Low back pain causes more disability than any other conditions.
- Prevalence increases up to the 6th decade.
- Most common in Western Europe - roughly 10% of the population have back pain.
- Slightly more common in women.
How do we assess symptoms for back pain? (LO2)
- Symptoms.
- Assess if nerve root irritation is present.
- Nerve root irritation tests.
- Document neurological signs.
- Exclude cauda equina syndrome.
Describe the epidemiology of lower back pain (LBP). (LO2)
- 90% of all back pain.
- Exact causes are hard to identify.
- Onset 20-55 years.
- Poorly localised, usually lumbosacral but may radiate towards the buttocks and thighs.
- Pain worse towards end of the day.
- Patient is systemically well.
Describe the prognosis for mechanical back pain. (LO2)
- Good.
- 50% of patients are better within a week.
- 90% of patients are better within 6 weeks.
Why is physical activity recommended for back pain? (LO2)
- Rest perpetuates disability.
- May relieve venous congestion and oedema.
- Muscular activity may interfere with pain signal processing.
- Spinal movement may have a similar effect.
Describe the initial management of back pain. (LO2)
- Examine the patient.
- Ask them to wait 1 week.
- If not improved in a week, ask them to wait 6 weeks.
- If still not improved then further investigations required.
- Do not refer for investigations unless high risk of poor outcome.
- Imaging in specialist settings of care only if the result is likely to change management.
- Educate on how to self-manage their low back pain with or without sciatica and encourage continuation of normal activities.
- Group exercise programme.
What 3 types of assessments carried out if a patient with back pain isn’t better after 6 weeks? (LO2)
- Biological assessment.
- Psychological assessment.
- Social assessment.
Describe the biological assessment of a patient with back pain lasting >6 weeks. (LO2)
- Check for nerve root problems.
- Red flags?
- Check CRP.
- Lumbar spine x-ray if relevant.
Describe the psychological assessment of a patient with back pain lasting >6 weeks. (LO2)
- Unjustified fears?
- Depressed?
Describe the social assessment of a patient with back pain lasting >6 weeks. (LO2)
- Family relationships.
- Work problems.
Describe the presentation of nerve root pain. (LO2)
- Unilateral leg pain > back pain.
- Numbness and paraesthesia.
- Nerve irritation signs.
- Motor sensory or reflex change - limited to one nerve root.
- Radiation below the knee.
Which nerve roots usually lead to nerve root pain? (LO2)
- 83% of prolapsed intervertebral discs will involve L5 or S1 roots.
- L5: 51%.
- S1: 22%.
- L5 AND S1: 10%.
- L3 or L4: 17% (usually in the elderly).
Define radiculopathy. (LO3)
Nerve root dysfunction often from mechanical compression. Inflammatory cytokines from damaged intervertebral discs also cause symptoms.
How many types of radiculopathy are there? Name them. (LO3)
3 types:
- Cervical radiculopathy.
- Thoracic radiculopathy.
- Lumbar radiculopathy/lumbosacral radiculopathy (sciatica).
Describe the epidemiology of each radiculopathy. (LO3)
Cervical radiculopathy:
- 107.3 per 100,000 in men.
- 63.5 per 100,000 in women.
- Risk factors - age (secondary to degeneration of spine).
Thoracic radiculopathy:
- Uncommon.
- Often mistaken for shingles.
Lumbar radiculopathy:
- 3-5% population.
- Men mainly affected in their 40s.
- Women affected in their 50-60s.
- Risk factors: female, white ethnicity, age, physically demanding occupations.
List some common causes of radiculopathies. (LO3)
- Laterally herniated disc.
- Spondylolysis.
- Spondylolisthesis.
- Age-related degeneration.
- Spinal stenosis.
- Facet joint degeneration.
- Synovial cysts.
- Infection.
- Trauma.
- Osteoporosis.
- Vertebral compression fractures.
List some rare causes of radiculopathies. (LO3)
- Radiation.
- Diabetes.
- Malignancy.
- Meningeal-related disease processes.
Describe the pathophysiology of radiculopathies. (LO3)
- Compression of a nerve root (can be sudden or gradual onset).
- Gradual onset can be due to impingement from bony osteophytes into the intervertebral foramen.
- Impingement of the nerve root can cause localised ischaemia/nerve damage (mechanical and chemical pathways).
- The chemical cascade is triggered by the nucleus pulposus.
- Disc degeneration and local ischaemia trigger the pro-inflammatory cascade, involving TNF-α, IL-6 and matrix metalloproteinases and prostaglandins.
- This leads to further sensitisation and increased pain.
Which nerve roots are commonly affected in cervical radiculopathy? (LO3)
C7 root is most commonly affected due to C6-C7 disc herniation.
C6 (C5-C6 herniation) and C8 (C7-T1 herniation) are also common.
Which nerve roots are commonly affected in lumbosacral radiculopathy? (LO3)
- L3-L4 root compression = pain radiates to anterior thigh.
- L5-S1 nerve root most commonly affected = “classical sciatica” - pain and tingling radiating down the posterior leg and into foot.
Describe the general presentation of radiculopathies. (LO3)
Dependent on impinged nerve roots.
- Sensory deficits/paraesthesia: burning, tingling, numbness.
- Pain described as shooting or electrical shocks.
- Reduced reflexes.
- Muscle weakness.
Describe the common presentation of cervical radiculopathy. (LO3)
Pain:
- Neck.
- Arm.
- Hand.
- Finger.
- May radiate along the distribution of affected nerve root.
- Rigid pain.
- Pain is worse on movement.
Describe the common presentation of cervical radiculopathies according to the common nerve roots affected. (LO3)
C5:
- Sensory loss of dorsal upper arm.
- Muscle weakness of the biceps, deltoid and spinati.
- Biceps reflex lost.
C6:
- Sensory loss of lateral arm.
- Muscle weakness of the brachioradialis.
- Supinator reflex lost.
C7:
- Sensory loss of dorsal arm.
- Muscle weakness of the triceps, fingers and wrist extensors.
- Triceps reflex lost.
Describe the common presentation of thoracic radiculopathies according to the common nerve roots affected. (LO3)
Pain in chest and torso.
Describe the common presentation of lumbar radiculopathies according to the common nerve roots affected. (LO3)
Sciatica.
List the differentials for radiculopathies. (LO3)
- Peripheral nerve entrapment syndrome.
- Shoulder pathologies.
- Shingles.
- Ankylosing spondylitis.
- Epidural abscess.
- Inflammatory arthritis.
- Inflammatory bowel disease.
- Leukaemia.
- Lumbosacral disc injuries.
- Lymphoma.
- Metastatic carcinoma.
- Multiple myeloma.
Describe the investigations for radiculopathies. (LO3)
Must rule out red flags.
- History.
- Physical exam - straight leg raise test (for sciatica).
- Neurological exam of upper and lower limbs.
- MRI/CT myelogram (contrast dyes) to confirm.
- If NO trauma indicated and only isolated cervical pain then no imaging required.
Describe the management of radiculopathies before the 6 week mark of the patient experiencing symptoms. (LO3)
Conservative treatment up to 6 weeks:
- Immobilisation.
- Anti-inflammatories.
- Physiotherapy.
- Epidural steroid injections.
- Cervical traction (benefits disputed).
Describe the management of radiculopathies AFTER the 6 week mark of the patient experiencing symptoms. (LO3)
Persistent symptoms after 6 weeks of conservative treatment/significant functional deficity is an indication for surgery.
- Anterior cervical decompression and fusion.
- Micro laminectomy (complete removal/partial removal).
- Posterior cervical foraminotomy/discectomy.
- Cervical disc arthroplasty.
Describe the prognosis of radiculopathies. (LO3)
- Typically self-limiting.
- 75-90% of patients’ symptoms improve without operations.
What is cauda equina syndrome? (LO4)
Compression of the nerve roots forming the cauda equina (the tail end of the spinal cord). Cauda equina syndrome is a surgical emergency, requiring urgent intervention to prevent permanent neurological deficits.
List the two types of cauda equina syndrome. (LO4)
- Incomplete - complaints about urinary difficulty, altered urinary sensation, loss of desire to void, hesitancy and urgency.
- Complete - definitive urinary retention with associated overflow incontinence.
Describe the epidemiology of cauda equina syndrome. (LO4)
- 1 person per 33,000-100,000.
- Most commonly due to a herniated lumbar disc.
Describe the presentation of cauda equina syndrome (from history taking). (LO4)
- Severe back pain.
- Bilateral sciatica.
- Perianal ‘saddle’ paraesthesia.
- Bowel and bladder dysfunction.
- Sexual dysfunction.
- History of spinal pathology or malignancy.
- Past spinal operations.
- Occupation and functional status.
Describe the findings of a lower limb neurological exam as an investigation for cauda equina syndrome. (LO4)
- Hypotonia - decreased tone.
- Bilateral or unilateral weakness.
- Areflexia - absence of deep tendon reflexes.
- Abnormal sensory changes.
Describe the findings of a rectal exam as an investigation for cauda equina syndrome. (LO4)
- Saddle anaesthesia - reduced sensation in the area that would be in contact with a saddle if sitting on one (perineum, buttocks, anus, groin and upper thighs).
- Reduced perineal sensation.
- Reduced ANAL SPHINCTER TONE - this is a red flag.
Describe the findings of an abdominal exam as an investigation for cauda equina syndrome. (LO4)
The following findings are considered to be red flags for CES according to NICE guidance:
- Severe bilateral deficit of legs.
- Recent onset urinary retention.
- Recent onset faecal incontinence.
- Perianal or perineal sensory loss.
- Unexpected laxity of anal sphincter.
Describe the investigations for cauda equina syndrome. (LO4)
- MRI of the spine as soon as possible.
- Many abnormalities can cause cauda equina syndrome.