Backpain

Question 1

Function of the spine?

Answer 1

• The spine allows a range of movement
• The spine protects our spinal nerves
• The spine functions as a shock absorber (as do the legs)
• This occurs because the spine is flexible, and is supported by strong muscles and tendons
• If this is lost, we lose the ability to protect ourselves from abnormal shocks and vibrations

Question 2

What are the 3 curves of the spine?

Answer 2

1. Cervical lordosis
2. Thoracic kyphosis
3. Lumbar lordosis

Question 3

Which part of the spine is the most mobile? Why?

Answer 3

The cervical spine - due to having relatively thick discs in comparison to the size of the adjacent vertebrae

Question 4

Diagram of intervertebral discs. What 2 components is it made up of?

Answer 4

1. Annulus fibrosis (outer portion)
2. Nucleus pulposus (inner squidy portion)

Question 5

What occurs during a slipped disc?

Answer 5

Occurs when the intervertebral disc’s outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus ruptures out of its normal space. If the annulus tears near the spinal canal, the nucleus pulposus material can push into the spinal canal.

Question 6

How does the composition of the intervertebral discs change throughout the day?

Answer 6

• In the morning they are swollen with water so the annulus and intervertebral ligaments resist bending strongly
• More vulnerable to injury as the day progresses as discs lose up to 20% of their water and height so the spine is more supple
  
  • Low back pain can increase during the day and with standing.

Question 7

How do intervertebral discs change with age?

Answer 7

• —Discs lose water and lose strength and become thinner
• —Vertebral endplates and underlying bone structure loses strength
• —Repetitive loading/trauma can result in annular tears in the discs
• —Dryer, weaker discs result in slacker ligaments
• —Spine is less stable
• —New bone grows (osteophytes) to try to stabilise the spine
  
  • —Increased load over the facet joints

Question 8

What should be told to patients with lower back pain?

Answer 8

Keep flexible and keep strong –> keeps back less stiff

Question 9

What determines back pain?

Answer 9

• —Genetics
• —Environment
• —Body weight
• —Muscle strength
• —Mechanical loading strengthens vertebral bodies and increases the water content within discs
• —OVERloading should be avoided

Question 10

What are the risk factors for low back pain (LBP) at work?

Answer 10

• —Heavy physical jobs
• —Lifting
• —Driving to work
• —Previous episodes of LBP
• —Mental health
• —Posture- laptops, seating, desk set-up

Question 11

Low back pain (LBP) can either be: simple backache, nerve root involvement or even possible serious spinal pathology.

What is the history of mechanical (simple) back pain?

Answer 11

• First episode often sudden onset while lifting/twisting/turning
• Recurrent episodes with decreasing inter-episode frequency
• Variable pain related to position/posture
• Better lying flat
• May radiate to buttock and leg
• Often worse at the end of the day and better with lying down/resting

Question 12

100% of people over 65 years have radiological changes in their spines. What are examples of these changes?

Answer 12

• facet arthritis
• disc narrowing
• osteophytes

Question 13

What are the guidelines for LBP - early management

Answer 13

• —Simple analgesics
• —Physiotherapy if symptoms > few days
• —Rest for no longer than 1-3 days
• —Psychosocial management
• —Work absence only if unavoidable
• —Early return to work, possibly graded
• —Consider secondary care referral if on going at 6 weeks

Question 14

What are the drug treatments for LBP?

Answer 14

• —Paracetamol
• —NSAIDs
• —Opioids
• —Anti-depressants (amitriptyline, duloxetine)
• —Nerve modulators (gabapentin, pregabalin)

Question 15

What is sciatica?

Answer 15

Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.

Question 16

What are the nerve roots of the sciatic nerve?

Answer 16

L4 to S3

Question 17

What can cause sciatica?

Answer 17

• When the sciatic nerve becomes pinched, usually by a herniated disk in your spine or by an overgrowth of bone (bone spur) on your vertebrae.
• More rarely, the nerve can be compressed by a tumor or damaged by a disease such as diabetes.

Question 18

Symptoms of sciatica?

Answer 18

• —Pain radiating from the back to the leg below the knee
• —May be associated with pins and needles in leg
• —May be associated with numbness and weakness
• —Commonest neurological sign is loss of ankle jerk
• —Commonest weakness is foot drop

Question 19

What is the commonest neurological sign of sciatica?

Answer 19

Loss of ankle jerk

Question 20

What are rheumatology back pain diagnoses?

Answer 20

• —Degenerative disease
• —Axial Spondyloarthritis
• —Osteoporosis
• —Osteomalacia
• —Paget’s disease
• —Infection
• —Tumour

Question 21

What are the ‘red flag’ symptoms for back pain?

Answer 21

• —Age (young or old) at first onset
• —History of carcinoma
  
  • Breast, kidney, prostate, lung, thyroid are most likely to spread to bone
• —Weight loss
• —Constant (24h) pain > 1 month
• —No response to treatment
• —Pain worse at rest
• —History of IV drug abuse or HIV positivity or immunosuppression
• —Infections

Question 22

Inflammatory back pain history:

Answer 22

• —Insidious onset
• —Nocturnal pain with marked early morning stiffness
• —Better with exercise
• —Worse with rest
• —Family history
• —Buttock pain- can alternate

Question 23

What is axial spondyloarthritis? Symptoms?

Answer 23

Axial spondyloarthritis is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac (SI) joints. Affects young people (men > women).

Symptoms:

• Back pain (main symptom)
• pain and stiffness in the spine
• other joint inflammation
• enthesitis
• iritis
• FH of associated diseases (IBD, psoriasis)

Question 24

What is osteoporosis?

Answer 24

Osteoporosis is a bone disease that causes a loss of bone density, which increases your risk of fractures.

Question 25

What is osteoarthritis?

Answer 25

Osteoarthritis is the result of every day wear and tear, and is most common in older adults

Question 26

What are the risk factors for osteoporosis?

Answer 26

The 'silent' disease. Risk factors: * Age * Female (oestrogen) * Smoking * Steroids * Alcohol * Family history * Inflammatory conditions

Question 27

What is osteomalacia? What is it most often caused by? What feature can be seen in xrays?

Answer 27

Osteomalacia refers to a marked softening of your bones, most often caused by severe vitamin D deficiency (diet, sunlight). **Looser zones,** also known as cortical infractions, are wide, transverse lucencies with sclerotic borders traversing partway through a bone and are associated most frequently with osteomalacia and rickets.

Question 28

What is Paget's disease? Symptoms?

Answer 28

* Paget's disease of bone disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed. * Prevalence increases with age. * Commonest site is pelvis * Symptoms: * Often asymptomatic – raised alkaline phosphatase * Pelvic/back pains. * Can cause spinal stenosis.

Question 29

What symptoms would be associated with neoplastic/infection causing back pain?

Answer 29

* —Insidious onset, sometimes subacute * —Slow deterioration * —24 hr pain * —Weight loss * —Associated symptoms * —Sometimes fever

Question 30

What is cauda equina syndrome?

Answer 30

Cauda equina syndrome is a rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed --\> surgical emergency

Question 31

Symptoms of cauda equina syndrome?

Answer 31

* —Difficulty with micturition * —Loss of anal sphincter tone or faecal incontinence * —Saddle anaesthesia * —Low back and/or leg pain

Question 32

When would surgery be a treatment for back pain?

Answer 32

* —Cauda equina syndrome * —Spinal stenosis * —(sciatica) * —Tumour/infection * —Instability