Transcript Slide 1

Managing the
Patient with
Back Pain
Nick Pendleton
April 2012
Back pain is the second
most common cause of
long-term sickness in
the UK after stress
About 9.3 million
working days were lost
due to work-related
back pain and other
musculoskeletal
disorders in 2008/09
I. Ache
Back Pain
X
X
D. R.
The Surgery
Bolton
The most common
causes of back pain are
strained muscles or
ligaments, wear and
tear, bad posture and
stress
BUT WHAT ELSE CAUSES BACK PAIN?
What else could cause
Back Pain?
Common Causes of Back Pain:
• Mechanical (muscular) back pain
• Prolapsed lumbar disc: nerve root
pain
• Spondylosis (exacerbation)
• Pyelonephritis and renal stones
• Pelvic infection
Hopcroft & Forte, Symptom Sorter, 4th Ed
Spondylosis?
• Degenerative osteoarthritis of the joints
between the of the spinal vertebrae and/or
neural foraminae
• Narrowing between 2 adjacent vertebrae
causes compression of emerging nerve roots
causes a radiculopathy
• Radiculopathy = sensory and motor
disturbances, such as severe pain in the neck,
shoulder, arm, back, and/or leg, accompanied
by muscle weakness.
Not be Confused with...
Spondylitis is an inflammation of the
vertebra.
Spondylolysis is a defect of the pars
interarticularis of the vertebral arch
Spondylolisthesis is the anterior or
posterior displacement of a vertebra or
the vertebral column in relation to the
vertebrae below
Spondylolisthesis
Less common causes
of back pain
• Spondyloarthritides
eg. Ankylosing Spondylitis
• Neoplastic disease
eg. metastases, myeloma
• Duodenal ulcer/acute pancreatitis
• Depression & anxiety states
• Vertebral collapse due to
osteoporosis
Hopcroft & Forte, Symptom Sorter, 4th Ed
BONY BRIDGES DEVELOP BETWEEN VERTEBRAE
GIVING ANKYLOSING SPONDYLITIS ITS CHARACTERISTIC
XRAY APPEARANCE – bamboo
spine
ANKYLOSING SPONDYLITIS
• Typical patient – young male 20-40
• Gradual onset chronic pain & stiffness in spine,
severe at rest, improves with activity
• Average onset to diagnosis time > 8.5 years
• Iritis & uveitis associated with AS
• HLA- B27 genetic association in 90% but only
5% of people with HLA- B2& get AS
• ANCA +ve, Rh F –ve.
• TNFα and IL-1 +ve implicated.
Diagnosis & Treatment of AS
• History & clinical examination
• MRI/Xray (syndesomophytes)
• Blood tests for markers +/- CRP/ESR
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No Cure
Symptom control
NSAIDs, Opiods,
DMARDS, TNFα blockers (eg etanercept)
Physiotherapy & exercise when inflammation
controlled
Rare but still really important
Causes of Back Pain
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Spinal Stenosis
Osteomalacia
Aortic aneurysm
Pancreatic cancer
Spondylolisthesis
Osteomyelitis
Malingering
Hopcroft & Forte, Symptom Sorter, 4th Ed
Mr Rob Gardener, 32
• Lifting paving slabs and heavy plant pots
• Felt ‘something go’
• Acute severe low back pain for last few days,
‘pain shoots down one leg’
• Can walk with difficulty
• Hasn’t taken any analgesia
• ‘didn’t want to mask the pain’
• Assessment ?
• Management ?
Mrs Brenda Cook, 49
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Low back pain on and of for last 5 years
Aching pain, worse on movement
Has taken ibuprofen, some help
BMI 35
Works in a school kitchen
• Further questions
• Examination
• Management
The Back Book (RCGP)
• http://download.lww.com/wolterskluwer_vita
lstream_com/PermaLink/BRS/A/00007632920011201-00008.PDF
Mr Fabian Cutter, 31
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Trainee Upper GI Surgeon
Aching pain in thoracic spine
Onset 18 months ago
Some relief with NSAIDs
Hurts when resting, Relieved by activity
Worried his back pain may affect his work
Has done some reading and wants some
investigations for....
• Ankylosing spondylitis
• What would you do?
Mr Harold Harrison, 80
• Thoracic backache and rib pain, worse
with activity
• Onset 2-3 months ago, Worsening with
time
• Recently thirsty, constipated and
nauseous
• What is the differential diagnosis?
• What investigations could you do?
What is Multiple Myeloma?
• Plasma cell in Bone Marrow becomes
malignant
• Plasma cells are a type of WBC
• Plasma cells produce immunoglobulins
• Plasma cell clones multiply and accumulate in
bone marrow
• Immunoglobulins (antibodies) are also known
as ‘paraproteins’
• The malignant plasma cells make vast
quantities of Ig’s = paraproteinaemia
Myeloma
• The type of paraproteinaemia depends on the
type of plasma cell which became malignant
• Commonest is IgG Myeloma
• The plasma cell tumours are known as
plasmacytomas, they spread and damage
bone affecting multiple areas of the skeleton
• This causes Hypercalcaemia
• The paraproteins cause renal damage
Myeloma can lead to.....
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Pathological fractures
Nerve compression
Renal failure
Bone pain
Hypercalcaemia symptoms
Anaemia
Thombocytopaenia
Serious infections (only 1 type of Ig)
Hyperviscosity
MYELOMA SCREEN
• Full blood count
• ESR or plasma viscosity
• Urea, Creatinine, Calcium, Albumin
• Electrophoresis of serum and concentrated
urine including 24 hour Urine for Bence-Jones
Protein light chains (typical antibody = 2 light
chains + 2 heavy chains)
• +/- Xray of painful region, lytic lesions,
pathological fractures
Dr Henry Bence-Jones
developed a light chain protein urine test in 1847
English chemist and physician, Fellow of RCP &
Royal Society, also wrote a book on the life of
Faraday, had 7 children with daughter of the
Earl of Gosford. Died in London in 1873
What is the Treatment for
Myeloma?
• Young patients who can tolerate aggressive
treatment – Stem Cell Transplant (autologous or
allogeneic)
• Following 6-9/12 treatment with:
• Chemotherapy + Steroids +Thalidomide
• Older patients >70: mephalan, pred &
thalidomide (MPT)
• Treatment for 12-18 months, 80% respond, well
for 2-3 years and then relapse
Thalidomide
• Recently approved for use in combination
with steroids for the treatment of newly
diagnosed Multiple Myeloma
• Interferes with signals affecting myeloma
cell multiplication and spread
• Inhibits new blood supply (angiogenesis)
• Patients must not become pregnant or
father children on treatment with
thalidomide
Identifying Spinal Cord
Compression –
Key Red Flags
Including a Summary of a Recent Presentation by Sue
Greenhalgh & Colleagues, Bolton Orthopaedic CATS
Significant Event Reviews
• Case reviews of the consultation histories of
patients diagnosed at a late stage with
sinister back pain have shown that Red Flags
were present at an early stage
• Wider knowledge of Key Red Flags for sinister
back pain could lead to earlier diagnosis and
a better outcome for the patient
• Sinister causes of back pain include
Metastatic Disease and Spinal Abscesses
Spinal Cord Anatomy
The Cauda Equina
• The cauda equina is formed by nerve roots distal to
the level of spinal cord termination (Usually L1/L2).
Cauda equina syndrome is caused by compression
of these nerves
• Compression can occur by trauma, vertebral
fracture or displacement, disc herniation, a
tumour or metastatic deposit or an abscess
• Because permanent neurological damage can occur
early identification and urgent treatment is critical
Cauda Equina Syndrome
Low back pain and:
• Bladder dysfunction, usually retention.
• Sphincter disturbance
• Saddle anaesthesia
• Lower limb weakness
• Gait disturbance
• Urgent referral is mandatory
Pain and Deficits Associated with Specific Nerve Roots
Nerve Root
Pain
Sensory
Deficit
Motor Deficit
Reflex Deficit
L2
Anterior medial
thigh
Upper thigh
Slight quadriceps
weakness; hip
flexion; thigh
adduction
Slightly diminished
suprapatellar
L3
Anterior lateral
thigh
Lower thigh
Quadriceps
weakness; knee
extension; thigh
adduction
Patellar or
suprapatellar
L4
Posterolateral thigh, Medial leg
anterior tibia
Knee and foot
extension
Patellar
L5
Dorsum of foot
Dorsum of foot
Dorsiflexion of foot
and toes
Hamstrings
S1-2
Lateral foot
Lateral foot
Plantar flexion of
foot and toes
Achilles
S3-5
Perineum
Saddle
Sphincters
Bulbocavernosus;
anal
Metastatic Spinal Cord Compression (MSCC)
Metastatic Spinal Cord
Compression (MSCC)
• Can happen at any level of the spinal
cord
• A search of the literature has shown
that 163 Red Flags for sinister back
pain have been identified!
• ‘Which of these are most useful for
identifying MSCC at an early stage?’
Early Warning Signs of
Metastatic Spinal Cord Compression
• Referred pain that is segmental or band-like
• Escalating pain which is poorly responsive to treatment
(including medication)
• Different character or site to previous symptoms
• Funny feelings, odd sensations or heavy legs (multisegmental)
• Lying flat increases pain
• Agonising pain causing anguish & despair
• Gait disturbance, unsteadiness, especially on stairs (not just
a limp)
• Sleep grossly disturbed due to pain being worse at night
Greenhalgh & Selfe 2009
Metastatic Spinal
Cord Compression
• NB- Established motor/sensory/bladder/bowel disturbances
are late signs
• Past Medical History of Cancer (but note 25% of patients do
not have a diagnosed primary)
• Early Diagnosis is Essential as the prognosis is much worse
once paralysis occurs
• A Combination of Red Flags increases suspicion (the greater
number of red flags the higher the risk and the greater the
urgency)
• To access the MSCC guidelines go to www.gmccn.nhs.uk
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NHS Greater Manchester and Cheshire Cancer Network
Greenhalgh & Selfe 2009
Mrs Jane Judge, 41
• Longstanding low back pain
• Known degenerative lumbo-sacral disc
disease
• On tramadol & gabapentin
• Acute exacerbation of pain
• Difficulty walking and hasn’t been able to
get to the bathroom to pass urine
• Home visit
• Describe the assessment you would do?
Lumbar disc prolapse causing
Cauda Equina Syndrome
Mr Max Matthews, 68
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Smoker. Retired Banker
Had Colon Cancer in 50s
Recent lower urinary tract symptoms
Thoracic back pain
Worse on lying down
Wakes him up at night
Pain steadily increasing
Feels like a band around his chest
Using increasing amounts of analgesia
Today we have covered....
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Causes of back pain (common and rare)
Simple mechanical back pain, acute
Chronic back pain
Spondylopathies
Ankylosing Spondylitis
Multiple Myeloma
Cauda Equina Syndrome
Metastatic Spinal Cord Compression