WEEK 3 - MINI LECTURES - LBP Flashcards
Prevalence of LBP
- 1/5 of global population
- 1 months: 30 %
- lifetime: 40%
- less than 2/3 will recover
- 1/2 will have recurrence in next year
- peaks at about 50%
Functional spinal unit
- nucleus - loss of PG/calcification
- Annulus: fissures/ tears/ nerve ingrowth
- subchondral bone: sclerosis, increased BMD, inflammation, schmorl’s nodes
- Nucleus extrusion: cord compression, radiculopathy
- Facet joint OA
- supra and interspinous ligament
- all injuries are related
End plate driven disc degeneration
- associated with endplate defects
- upper lumbar and thoracic spine
- higher heritability
- occurs before afe 30
- moderate pain
- caused by spinal compression
Annulus driven intervertebral disc degeneration
- associated with annulus fissure
- lower lumbar spine
- lower heritability
- rarely before age 30
- strong association with pain
- caused by spinal bending
Red flags for back pain
- constitutional symptoms
- immunosuppression
- history of malignancy or unexplained weight loss
- trauma
- prolonged use of corticosteroids
- osteoporosis
- neurological signs and symptms
- failure to improve after 4-6 weeks
If red flags present, what do you order?
- plain radiograph
If after the radiograph the cause of back pain is still uncertain
- MRI
If MRI is contraindicated or not available
CT
- suspected bony metastses or multifocal infection
- Bone scan
Sciatica/radiculopathy: do we do imaging?
- no, unless pain not improving or the neurological deficit is progressing
Possible cord or cauda equina compression - imaging?
- yes, urgent imaging required -> MRI
Possible spinal canal stenosis - imaging?
- only if indicated
Epidural space
- between dura and surrounding vertebral canal
- contains fat, loose connective tissue, small arteries, veins, lymphatics
Subdural space
- potential space between dura, outer surface of arachnoid
Subarachnoid space
- between inner surface of arachnoid and Pia
- contains CSF, vessels, spinal cord ligaments, nerves, filum etrminale
- continuous with intrachranial SAS
Extradural compartment
- epidural space
- vertebral bodies, neural arches, intervertebral discs, muscles
Intradular extramedullary compartment
- SAS
- spinal cord ligaments
- nerve roots
- cauda equina
- filum terminale
Imtramedullary compartment
- spinal cord,
Pia
Treating non-specific LBP
- conservatively
Sciatica/canal stenosis
- initially conservative
- then surgical
Acute non-specific LBP
- first line care
- advice
- simple analgesics
- review
Acute non-specific LBP
- second line care
- Medicines: compound analgesics, NSAIDS, muscle relaxant, opioids
- Physical therapies: spinal manipulation, heat wrap therapy
Persistent non-specific LBP
1) advice + simple analgesic
2) Complex medicine, physical therapy, psychological therapy
3) multidisciplinary pain clinic
STarT back approach
- triage
- physio directs care
- standardised physiotherapy, minimal treatment, advice, medicatin
BioPsychoSocial model to treat back pain
- Bio: range of motion, strength, endurance
- psycho: emotions, beliefs, distress
- Social: sick role, culture, family, work situation
MPS model vs usual care
- additional benefits for pain
- additional benefits for disability
- no difference for work
BPS vs physical treatment
- additional benefit for pain
- additional benefit for disability
- additional benefit for work
Surgical options for non-specific LBP
- fusion of two vertebrae together on one or more levels. Evidence suggest it is no better than structured alternative treatments
- disc replacement: evidence of mild benefit over fusion
Causes of sciatica (2 common causes)
- acute disc protusion
- chronic degenerative lumbar spine stenosis (in older patient)
Surgical options for sciatica
- discectomy
- laminectomy (remove lamina or posterior spinal process)
Evidence for surgery for acute disc protrusion
- short term benefit to surgery but no difference in long term
Evidence for surgery for Lumbar spine stenosis
- poor evidence to support surgery or to distinguish between surgical alternatives
Injection therapy for back and leg pain
- commonly performed for LBP
- commonly performed for sciatica
- usually corticosteroids and local anesthetic
Different routes of injection for back and leg pain
- central epidural
- facet joint
- transforaminal
- disc space
Evidence for injection therapy
- no long term benefit over placebo
- small shrot term benefit over placebo
- no advatage of any one method
- no benefit in any diagnosis
Cancer redflags
- history of cancer
- age over 50
- unexplaiend weight lost
- failure to improve after 1 months
- nocturnal pain
Cancers causing back pain
- cancers that metastasize to bone: lung, breast, prostate, thyroid, kidney
- rarer: leukemia, lymphoma, myeloma
Infection red flags
- NOT ALWAYS FEVER
- underlying medical conditions: diabetes, coronary heart disease, immunosuppressive disorders
- cancer
- renal failure
- IV drug use
Diagnosis and management of infection as a cause of back pain
- most common organism is staph aureus, followed by E coli
- aspirate and send for culture before antibiotics
- treatment is antibiotic for 3 months, and surgical decpompression if neurological function is compromised
- MRI sensitivity: 90%
Fracture as a cause of back pain red flags
- diagnose with X ray or technetium bone scan
- red flags: prolonged use of steroids, age > 70, trauma
- most common redflag condition
Cauda equina syndrome red flags
- dysfunction of bladder, bowel or sexual function
- sensory changes in saddle or perianal area
Cauda equina syndrome: causes
- degenerative disc/spinal disease
- tumours
- infection
- trauma
- investigation by MRI
Treatment of cauda equina syndrome
- urgent surgical decompression
4 kinds of spondyloarthropathy
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis
AS epidemiology
- Prevalence is 0.1-1.4%
- Male:Female is 3:1
- Peak age onset: 20-30 years
- affects spine and peripheral joints
- 75% present with back symptoms
- sacroiliitis - required for diagnosis
- inflammation occurs at enthesis
AS clinical features
- inflammatory back pain
- buttock pain - sacroiliitis
- fatigue, weight loss
- loss of lumbar lordosis
- reduced back movements
- pain on stressing sacroiliac joints
- reduced chest expansion
- bamboo spine
AS extraspinal features
- peripheral arthritis in 35-50%
- large joints: hips, knees, shoulders, ankles
Extra articular features continued
- inflammatory eye disease
- inflammatory bowel disease
- lung disease
- aortic valve disease
- psoriasis
Investigations for AS
- Hb, WCC and platelets normal
- ESR, CRP elevated especially if peripheral arthritis
- Xrays - sacroiliac joints and spine is essential
- syndesmophytes present
- HLA-B27 antigen
Management of AS
- exercise
- education
- NSAIDS
- TNF-inhibitors
BAck pain and return to work
- varies between and within countries
- depends on workers compensation insurance system
- vast majority will return to work
- 5-10% will not return to work after 12 months
- determinants are predominantly psychosocial
