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Polymyalgia Rheumatica
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Back Pain
Last updated 3rd December 2020
The challenge is to distinguish 95% simple mechanical back pain from 5% serious causes. Patients with cancer who develop back pain require urgent assessment by the specialist palliative care team.
Causes of Back Pain – Pnemonic MRI
Risk Factors for Serious Spinal Disorders (Red Flags)
- New onset of spinal pain at age < 20 or > 50 years
- Fever or night sweats.
- Weight loss.
- Pain that is non variable and progressive.
- Immunosuppression.
- Saddle anaesthesia.
- Urinary or faecal incontinence.
- Past history of malignancy
- Significant trauma
Compression Fracture
- Osteoporotic compression fractures are a common cause of back pain, but not usually of cord compression, in patients admitted as medical emergencies.
- Diagnosed by x-ray spine which shows anterior wedging of one or more vertebrae.
- Assessment should include breast exam, CXR, routine bloods, calcium, 25 Hydroxy vitamin D (if not checked in past year), phosphate, PSA, CRP and myeloma screen (including urine Bence Jones protein).
- If osteoporosis considered likely then MR not necessary, but if compression fracture occurs in patients with known malignancy then MR clearly indicated.
- Treat by analgesia, initially paracetamol with NSAID, and bed rest.
- If 25 hydroxyvitamin D < 25nmol/l give 6 week loading dose course vitamin D eg Stexerol D3 2 x 25,000 units per week followed by 1000 units daily or combined supplement such as Theical D3 1 tablet daily thereafter as maintenance. Also consider 5 year course of Alendronic Acid 70 mg per week, to be commenced following completion of loading dose vitamin D.
- If oral bisphosphonates not possible refer to Osteoporosis clinic (Dr Drever – 33023).
Spinal Stenosis
- Degenerative changes can encroach on the central spinal canal especially in the lumbar spine and may result in substantial stenosis.
- The classic presentation is neurogenic claudication characterised by unilateral or bilateral calf, thigh or buttock discomfort precipitated by walking and prolonged by standing and relieved by sitting (because flexion of the hip increases the available space in the spinal canal).
- Neurogenic claudication must be distinguished from vascular claudication in which the pain is relieved by rest.
- MR is investigation of choice.
- Surgical treatment by laminectomy is best option for severe stenosis.
Central Disc Herniation
- Herniation of an intervertebral disc is usually the result of degeneration of the disc.
- Central disc herniation can cause spinal cord compression or cauda equina syndrome (see below).
- Saddle anaesthesia and decreased anal tone on rectal examination means cauda equina syndrome until proven otherwise, which can also be due to malignancy or infection.
- Lateral disc herniation usually occurs at L4/L5 (causing foot drop) or L5/S1 (causing loss of ankle jerks) with pain that radiates down to leg (sciatica).
- MR is investigation of choice.
- Surgical discectomy provides effective clinical relief for carefully selected patients with sciatica due to lumbar disc prolapses that do not resolve with conservative treatment.
Malignancy
- Cancers commonly associated with spinal metastases include breast, prostate, lung, kidney, myeloma and lymphoma.
- Sites most frequently affected are thoracic (60%), lumbosacral (30%) then cervical (10%).
- May cause spinal cord compression or compression below the termination of the spinal cord (cauda equina syndrome).
- Clue to spinal cord compression is upper motor neurone weakness both legs, urinary retention and sensory level.
- Clue to cauda equina syndrome is lower motor neurone weakness both legs with saddle anaesthesia and loss of anal tone.
- Other clues to malignancy include weight loss, anaemia, hypercalcaemia, high ESR.
- Straight x-ray may show compression fractures or lytic lesions but MR is investigation of choice.
- Patients with suspected/confirmed cord compression should be referred to neurosurgery without delay.
Infection
- Vertebral osteomyelitis and spinal epidural abscess are two infectious causes of back pain that may lead to permanent neurological dysfunction if undiagnosed.
- Diagnosis should be considered in patients with red flags (see above).
- Investigations should include blood cultures, plain x-ray and MRI.
- Treatment consists of flucloxacillin plus fusidic acid for minimum of 6 weeks with CT guided percutaneous drainage if abscess present, with laminectomy and decompression of abscess if percutaneous drainage fails.
Psychosocial Obstacles to Recover (Yellow Flags)
- Fears and beliefs.
- Catastrophising.
- Compensation claims.
- Illness behaviour (the sick role).
- Depression and anxiety.
- Failure to accept medical reassurance