Week 3: Study Qs Flashcards
What are the common sacroiliitis diseases?
- RA
- Infections
- Seronegative arthropathies: AS, Reiter’s, Psoriatic arthritis, enteropathic arthropathies (Chronic, UC), undifferentiated spondyloarthropathies
What are the four general types of signs and symptoms associated with seronegative arthropathies?
MSK Spine: local SI inflammation, progressive, insidious, migratory P possible, P less influenced by body mechanics
MSK extra-spinal: concomitant joint pains (hip) enthesitis (commonly the heel, rotator cuff, greater torch, patella, tibial tubercle, base of 5th metatarsal, costochondral junctions), osteitis, synovitis
Non-MSK general: fever, malaise, fatigue, etc.
Non-MSK specific: rash, GI or GU disorders
What the signs and symptoms that suggest the presence of AS?
- Age <40 yo
- Sx 3+ months
- Morning stiffness <30 mins
- Improvement with exercise, not rest
- Wake 2nd half of night because of P
- Insidious onset
- Myospasm in glut max or piriformis
Areas of inflammation in AS?
Eyes 40% Neck 75% Rib/spine junction 70% Lumbosacral 50% Sacroiliac 100%
What two special physical examination procedures should be done?
- Schober’s test normal is at least 5cm
- Respiratory excursion normal is >5cm
- What eye-related symptoms might a patient have? How would the eye problem be managed?
20-40% patients get Uveitis: redness, photophobia, pain, blurry
TX: sunglasses, corticosteroids, antibiotics
What ancillary tests should be ordered?
- ESR or CRP
- CBC shows anemia of chronic disease (normocytic or normochromic)
- Likely (+) for HLA-B27
- Negative tests: Rh factor and anti-cup (for rheumatic arthritis), negative ANA
Radiographic evidence of SI
Mgmt plan for AS?
Manipulate in non-acute phase/blocking, mobilizing in acute phase.
STM g max, piriformis
Stay active between flare ups
Core spinal exercises w/ emphasis on extension, stretch muscles, postural training
• meds: NSAIDS, TNF blockers
What 5 screening Qs to ask if you suspect AS?
- morning stiffness?
- Improve with exercise?
- Onset pain before 40 yo??
- Slow onset?
- Pain persisting >3 months?
What are the components of the 4-part diagnosis?
Pathoanatomical
Neurological/radiating
Biomechanical
Complicating factors
What are the characteristics of the pathoanatomical diagnosis?
1˚ Dx and 1st for billing purposes (except Medicare) and gets ICD code.
Addresses: location of structure and type of (anatomical damage, inflammation, tearing of tissues) injury to that structure. Or a type of headache. Or a type of nerve entrapment.
What are some pathoanatomical Dx examples for low back pain?
Spinal canal stenosis Lumbar sprain/strain Lumbar facet syndrome Spondylolisthesis (if considered primary cause) Sacroiliac syndrome Sacroiliitis Ankylosing spondylitis
Pathoanatomical Dx Examples for neck pain?
Cervical sprain/strain Cervical facet syndrome Cervical stenosis (when primary) Guillain Barre syndrome Cervicocranial syndrome Cervical herniated disc Hyperextension-hyperflexion injury (acceleration-deceleration injury) Tension headache Vascular headache Cervicogenic headache Cervicobrachial syndrome Brachial traction injury Thoracic Outlet Syndrome T4 syndrome Maigne syndrome
Does the patient have to have pathoanatomical Dx?
Yes because its the 1˚ Dx in most cases
What are some examples of neurological components?
S1 radiculopathy into right foot
Deep referred pain (sclerotogenous) into posterior thigh
Left foot paresthesia
Myofascial pain referral over right eye
What are examples of biomechanical component?
Joint dysfunctions: segmental dysfunction, joint dysfunction, subluxation syndrome
Muscle dysfunctions: myospasm, MFTP, myofibrosis
Can there be more than 1 biomech component?
Yes
What is the first step in differential diagnosis for a low back pain patient?
Injury or disease
How common is serious disease as a cause of low back pain?
<3% of LBP is d/t serious disease
2:1 Belly:Back (1% is spinal, 2% is visceral)
What recommended ancillary tests do we usually start with for a patient with red flags?
If cancer or infection?
If arthritic condition?
If urinary problem?
Radiograph, then MRI, CT, bone scan
ESR or CRP
CBC
Cancer/infection: blood chem panel
Arthritis: anti-CCP, RF, ANA, HLA-B27
Urinary: UA
What are the 3 main indicators for ordering a radiograph?
- Red flags for disease
- Trauma
- Evidence of spinal neuro damage (radiculopathy, CES, neurogenic claudication)
Should age > 50 years old generally prompt a radiograph in patients with LBP?
No
What are two additional situations when you should consider ordering a plain film radiograph?
Suspicion of osteoporotic related compression Fx
Tx failure >1month
Are most metastatic spinal cancers osteolytic or osteoblastic? What is an example of both?
MC = osteolytic
Osteolytic=breast
Osteoblastic=prostate
Note: cancer spares the disc unlike infection
What 2 changes do you expect radiographically with a spinal infection?
End plates eaten away and eventually more of the bone will disappear.
Loss of disc (cancer spares the disc)
What blood tests are often increased in a spinal infection?
76-100% ESR
61% Leukocytosis
ESR stands for
Erythrocytes sedimentation rate
About how sensitive is a radiograph on the first patient visit to detect spinal cancer?
68% ability to detect cancer
68% of patients with metastatic/primary bone tumor will have an abnormal x-ray at their first visit.
What broad types of conditions (or categories of disease) should you consider when you see an elevated ESR or CRP?
Infections, cancers, inflammatory disease
Are ESR or CRP generally more sensitive or specific to particular diseases? And what does sensitive/specific mean?
They are sensitive (rule out), not very specific (rule in/point to specific condition).
So they are good for screening which means there are a lot of false positives.
Explain the 20-50 rule for the ESR (which should REALLY be called the 18-50 rule).
<18 mm/hr is normal
18-50 mm/hr is elevated
>50 is probably a significant disease requiring more testing and advanced imaging
What 3 disease processes are suspected when >100 mm/hr ESR?
Multiple myeloma
Temporal arteritis
Polymyalgia rheumatica
Which is more likely to be elevated in most bone cancers, the ESR or the total white count?
SED rate are more sensitive to catching cancer compared to white count
About how often does cancer cause anemia?
50% of the time
What types of anemia does cancer cause?
90% is normochromic normocytic
10% is microcytic
Which type of anemia is MC and what is LC?
MC: Normocytic normochromic anemia = 90% chronic disease anemia
LC: Microcytic is not common but chronic disease is the 3rd most common cause of microcytic anemias
What would be a blood test finding that would help you differentiate iron deficiency anemia from a microcytic anemia caused by a disease?
Iron panel to check Serum Iron and Serum Ferritin
If serum iron is decreased AND serum ferritin is decreased, what do you think?
Iron def. anemia probably not related to the LBP
If Serum iron decreased but normal/elevated serum ferritin?
Think of a disease state and do NOT supplement with iron
What CBC changes in the white cells might occur in a patient with cancer causing low back pain?
Decreased white cells
Increased WBC >11,500 is likely what disease?
Infection, cancer, inflammatory
Increased immature whites is probably what disease?
Leukemia
Decreased white cells is probably what disease?
MM or other cancers
What three tests on a blood chemistry panel could give you key information about bone cancers?
A. Calcium
B. Alkaline phosphatase (ALP)
C. Protein (globulins)
What are the two most common causes of hypercalcemia?
A. Metastatic cancer
B. Hyperparathyroidism
Note: never ignore even small increases in serum calcium >10.2 mg/dL. Usually not caused by osteoporosis, and 40-50% pts with metastatic cancer to bone will have elevated calcium.
What types of bone related conditions can raise ALP? (5)
Blastic lesions: Paget’s disease, healing Fx, growing bones, pregnancy, liver disease
What bone condition can raise ALP the most?
Paget’s disease
When do you order protein electrophoresis? And what are you looking for?
When globulins are elevated on serum protein test. Order protein electrophoresis to look for monoclonal spine suggesting multiple myeloma.
