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Dr Raj Sengupta
Low Back pain
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• Definitive diagnosis difficult – not made in 85%
• Distinguish benign, self limiting disease (95%) from serious disease (5%)
• When does a patient need further investigations/ referral to secondary care?
Introduction
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Low Back pain
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• sharp radiating pain often associated with numbness or paresthesia
• weakness and loss of reflexesL4: knee jerkL5: dorsiflexion, medial
sensationS1: plantarflexion, ankle
reflex, lateral sensation
• aggravated by coughing, sneezing, Valsalva
• most common cause is herniated disc
L4/5, L5/S1 most common
Sciatica
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• Compression of cauda equina
– Bilateral leg pain and weakness– Urinary retention, saddle anaesthesia,
reduced sphincter tone, bilateral sciatica
– Immediate referral for MRI or CT– Surgical consultation
Compression can be from degenerative changes, trauma, infection, tumour or haematoma
Cauda Equina Syndrome
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Disease of older adults
Caused by bone (facets, osteophytes) or soft tissue (bulging disc, ligamentum flavum enlargement)
Neurogenic claudication, numbness, tingling
Pain improved when seated or spine is flexed
Spinal stenosis
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Ankylosing Spondylitis
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The SpA are a group of related disorders that share distinctive clinical, radiographic and genetic features:
• Sacroiliitis and spinal inflammation
• Peripheral arthritis and enthesitis
• Extra-articular manifestations
• Strong association with Human Leukocyte Antigen (HLA-B27)
UndifferentiatedUndifferentiatedSpASpA
Juvenile chronic Juvenile chronic arthritisarthritis
ReactiveReactivearthritisarthritis
Ankylosingspondylitis
Psoriatic Psoriatic arthritisarthritis
Arthritis /Arthritis /spondylitis spondylitis
associated withassociated withIBDIBD
Linden VD. In: Kelley’s Textbook of Rheumatology. Ankylosing Spondylitis. 8th ed. 2009Sieper J. Arthritis Res Ther 2009;11:208
IBD – Inflammatory bowel disease
Spondyloarthritides
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• Age at onset <40
• Insidious onset
• Improvement with exercise
• No improvement with rest
• Pain at night (with improvement on getting up)
IBP if 4 or out 5 criteria presentSieper et al. Annals Rheumatic Diseases 2009;68: 784-788
Inflammatory Back pain
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Ankylosing Spondylitis
Reactive SpA IBD/ PsSpA USpA
95% 70-80% 50% 0-70%
Espinoza LR, Cuellar ML. Clinical aspects of the spondyloarthropathies. In: Lopez-Larrea C, ed. HLA-B27 in the development of spondyloarthropathies. Austin: Landes, 1996:1–16.
HLA B27 in SpA subtypes
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Role of MRI
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Axial Spondyloarthritis
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Case presentation
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• 22 years old from Milton Keynes
• 4 year history of back symptoms
• EMS 1 hour
• Symptoms better with activity
• Sleep disturbed
• Night sweats
• Father has AS
Ms NH
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• Saw GP – NSAIDs
• NSAIDS effective – ongoing symptoms
• Referral to orthopaedics 2008
• MRI requested 2008– normal
• Returned to orthopaedics several times
• MRI requested 2009 – normal
• Discharged – ongoing back symptoms
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RS clinic
• IBP symptoms
• MRI reviewed
• Correct MRI requested – Diagnosis made
• Patient frustrated and delay in diagnosis
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GP Inflammatory Back Pain Pathway
Back pain
Inflammatory back pain
Xray pelvis
Sacroiliitis on xray Normal
HLA B27 positiveRefer to me
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• Most patients with back pain have self limiting disease
• Some causes of mechanical back pain need further urgent investigations eg cauda equina
• Important to distinguish inflammatory spinal disease
Summary