RheumatologyFinal Med revision programme 2007-8RheumatologyFinal Med revision programme 2007-8

Dr. David KaneConsultant Rheumatologist

AMNCH & TCD

Disorders of the SpineDisorders of the Spine

Dr. David KaneRheumatologyAMNCH & TCD

General Principles (1)General Principles (1)90-95% of neck and back pain is benign / mechanical in nature

Pain due to overuse or strain of normal structures (muscle, tendon, fascia, ligament, nerve)Intervertebral disc prolapse (radiculopathy), usually self limiting but may become chronicDegenerative Disc DiseasePrecise diagnosis usually impossible and unnecessary

General Principles (2)General Principles (2)Objective of history / examination is to differentiate:

benign cases (requiring physio/ conservative management)

sinister cases (requiring immediate investigation)

Sinister back painSinister back pain

Remaining 5-10% of casesVertebral fracture (osteoporotic or pathological)Malignancy (myeloma, spinal secondaries)Infection (discitis or vertebral osteomyelitis)Inflammation (spondyloarthropathy)Referred pain from aortic aneurysm, pancreatitis, gastric ulcer etc

Back Pain : History (1)Back Pain : History (1)Pain

OnsetCharacter (boring, shooting, constant, intermittent)Radiation (up spine, down leg; ?below knee – sciatica)Precipitating / relieving factorsChange with coughing, Valsalva (radiculopathy)Nocturnal / sleep disturbance

Morning StiffnessAssociated neurological symptoms

Paraesthesiae / numbnessSphincter disturbance

Back Pain : History (2)Back Pain : History (2)Past Medical History

Malignancy, Skin rashesImmunosuppression, HIV, IVDAOsteoporosis risk factors

Corticosteroid use, malabsorption, alcoholism, hypogonadism

Family HistorySpondyloarthropathy, Psoriasis, Cröhn’s / Ulcerative Colitis

Social HistorySmoking, alcohol useEmployment history

“Red Flags”“Red Flags”Age <25 or >55 yearsInsidious onset, progressively worsening painAcute onset severe pain without antecedent traumaPain unaffected by activity / postureNocturnal pain disturbing or waking from sleepPain in the thoracic spineProgressive or bilateral neurological symptoms

Saddle anaesthesia, bladder/ bowel sphincter disturbance

Systemic symptomsFever, weight loss, general malaise

“Yellow Flags”“Yellow Flags”

Adversarial medicolegal proceedingsLow job satisfactionPsychosocial problems / depressionPersonal problems – alcohol, marital, financeDisproportionate illness behaviourTotal work loss (due to low back pain) >12/12

Causes of Spinal PainCauses of Spinal Pain“Mechanical“InflammatoryMalignantInfectionBone Disorders

Non-spinal causes of Spinal PainNon-spinal causes of Spinal PainNeck Pain

Disorders of the ShoulderVisceral pain: Ischaemic Heart disease, oesophageal spasm, Pleural inflammation, Dissecting aneurysmDiaphragmattic: Subphrenic abcess, Gall BladderSystemic: Meningitis

Low Back PainDisorders of the HipVisceral Pain: Pancreatitis, Colonic Carcinoma, Renal Calculi, Endometriosis, Ovarian Carcinoma, Abdominal aortic aneurysm

Mechanical neck and back painMechanical neck and back pain

Acute onset, associated with physical task or traumaRelieved by restWorse with movement / exerciseMorning stiffness < 30 minutes

Mechanical neck and back painMechanical neck and back pain

Trauma (includes Whiplash Injury)Degenerative disease

SpondylosisDisc herniationSpondylolisthesisSpinal Stenosis

Post Surgical back painMechanical Pain ….soft tissue strain

Osteoarthritis of cervical spineOsteoarthritis of cervical spine

Prevalence increases with agePrevalence increases with age

C5,C6,C7 most affectedC5,C6,C7 most affected

OsteophyteOsteophyte and discand discspace narrowing space narrowing

Osteoarthritis of Lumbar spineOsteoarthritis of Lumbar spine

RadiologyRadiology HistologyHistology

Nerve root pain (Radiculopathy)Nerve root pain (Radiculopathy)Acute onset after weight bearing activityUnilateral “shooting” pain radiating down to below knee; back pain less intensePain exacerbated coughing, sneezing, ValsalvaLimited flexion, but preserved rotation, extensionNeurological abnormalities (usually one root only)

L4: pain anteromedial thigh, ↓sensation over patellaL5: ↓sensation medial edge/ dorsum foot, can’t heel walkS1: ↓sensation lateral border/ sole foot, can’t walk on tiptoe

Lost tendon reflexes

Spinal StenosisSpinal StenosisNeurological compromise caused by degenerative narrowing of the lumbar spinal canalPseudoclaudication

Pain / paraesthesiae in buttock / leg precipitated by exercise and relieved by restWithout evidence of peripheral vascular diseaseUsually relieved by spinal flexion, exacerbated by extension

Signs may resemble sciaticaObjective neurological signs usually absentBladder / bowel compromise rare

But absolute indication for surgery

Role of imagingRole of imaging

Plain radiograph of variable valueIf radiculopathy or spinal stenosis present proceed to MRI

Non-pharmacological therapy:

EducationPhysiotherapy:

Exercise: Mobilisation not restactive/passive movementsHydrotherapyManipulationLocal treatment: heat /ultrasound / TENSExercise

Occupational Therapy

Analgesic therapy – neck and back pain

paracetomolcodeineCombinations

eg:-paracetomol + codeineNSAIDsLow dose diazepam Stronger opiatesAmitryptiline, Gabapentin. Pregabalin

Relative risk of G-I haemorrhage with NSAIDs

Current NSAID ........5.9Single NSAID ........4.9Switcher ........11Multiple ........11

Garcia-Rodriguez et al 1994

Minimisation of NSAID side-effects

Avoid in high risk patientselderlyfemaleHx. of P.U.D. / renal impairmentConcomitant aspirin, warfarin, SSRI

Use of gastroprotective agentsmisoprostilproton pump blocker

Cox-2 selective agents

Indications for SurgeryIndications for SurgeryAcute onset of spinal cord compression or cauda equina syndrome is a surgical emergency

3 general indications to consider surgeryNerve Root compressionSpinal cord compressionInstability

Fusion may be indicatedRequires careful pre- assessment

Inflammatory spinal painInflammatory spinal painYoung men (onset < 40)Insidious relapsing/ remitting onset, sometimes with prodromal illnessPresent for at least 3 monthsNocturnal pain; marked morning stiffnessNeck stiffness, particularly extensionRelated symptoms:

Uveitis / iritisPsoriasis, Keratoderma blenorrhagica, circinatebalanitisCröhn’s / Ulcerative colitisEnthesopathies

Progressive spinal deformity in Ankylosing SpondylitisProgressive spinal deformity in Ankylosing Spondylitis

Clinical features – ankylosing spondylitisClinical features – ankylosing spondylitis

Arthritis of axial skeleton sacroileitis spine pubic symphesis

Arthritis of limb girdle jointships shoulders

Inflammation of enthesesAchilles tendon olecranon plantar fascia

Is HLA B27 the only factor in Ankylosing SpondylitisIs HLA B27 the only factor in Ankylosing Spondylitis

Why if only 9% of UK population haveHLA B27 do only 0.05% have Ankylosing

Spondylitis?

Transgenic rats only get disease when grown in non sterile environment

Treatment for AnkylosingSpondylitisTreatment for AnkylosingSpondylitis

NSAIDSAnalgesicsIntensive physiotherapy/ hydrotherapyRadiotherapy was used? role of bisphosphonatesSurgery for fracturesAnti-TNF therapy

Hydrotherapy for EMSHydrotherapy for EMS

Malignant spinal painMalignant spinal pain

Metastatic DiseaseMultiple MyelomaPrimary tumour or bone, spinal cord or nerve root

Malignant spinal painMalignant spinal pain

Older patientsSevere unremitting pain with no relation to posture or activityNocturnal painWeight loss/ constitutional symptoms± Cord Compression:

Sensory levelSphincter involvement

InfectionInfection

OsteomyelitisParavertebral abcessDisciitis

Bone DisordersBone Disorders

OsteoporosisPaget’s Disease

Osteoporosis / vertebral fractureOsteoporosis / vertebral fracture

Only ~30-50% of osteoporotic vertebral fractures are symptomaticSymptomatic fractures:

Sudden onset, severe, well-localised dorsal/ lumbar pain, often after effort/ traumaPatient may even describe feeling a “crack”Settles gradually over 6-8/52

Asymptomatic fractures:Gradually increasing kyphosis with loss of height

Normal boneNormal bone

http://www.schoolscience.co.uk/content/

Normal boneNormal bone

http://www.teaching.anhb.uwa.edu.au/mb140/

Normal ElderlyNormal Elderly

50 58 76 84

Normal Osteopaenia Osteoporosis

Osteoporosis

‘…a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture’

Common sites of fracture1

Spine

Neck of femur

Wrist

Definition1

PathophysiologyPathophysiology of Osteoporosisof Osteoporosis

Osteoid Mineralization

Bone

RestingActivationResorption

Bone Osteoclasts

Bone Remodeling

ReversalFormation

BoneBoneOsteoblasts

1.000.820.83Survival

5%2-10%100%Hospitalisation

35008,0005000Cases / yr

13%2%

28%6%

14%3%

Lifetime Risk- women- men

WristSpineHip

Osteoporosis and Vertebral Fracture

Only 33% of vertebral fracturesare clinically diagnosed5

100%

50%

33%

8%2%

fractures identified by X-ray

symptomatic (back pain)

clinically diagnosed

admitted to hospitalrequiring long-term care

Vertebral morphometry now possible with DXA

Osteoporosis: causes

• Secondary– Glucocorticoid excess– Premature Ovarian Failure– Testicular Insufficiency– Thyroid Hormone excess– Diabetes Mellitus– Immobilization– Neoplasia-producing osteoclast activating factors,– Chronic inflammatory disorders– Primary biliary cirrhosis– Malnutrition– Chronic calcium or protein deficiency– chronic heparin therapy– Ethanol………….+cancer Rx……….+transplant

• Primary (ageing, post menopausal)

Step five:Arrange DXA7

Only undertake DXA if the results will influence management

Lifestyle measures7

• Smoking cessation• Avoid excessive alcohol intake• Regular weight-bearing exercise• Avoid immobility• Avoid excessive dieting and exercise resulting in amenorrhoea• Maintain adequate reference nutrient intakes of calcium/vitamin

D

Calcium males 11-18 years 1,000 mg dailyfemales 11-18 years 800 mg dailyadults 19 + years 700 mg daily

Vitamin D 800 IU daily

The RCP makes no recommendations concerning population-based strategies2

Clinical Effectiveness: Cyrus Cooper

0.490.810.55Alendronate

0.850.60Strontium

0.650.35rPTH

0.920.69Raloxifene

1.14 *0.55Ibandronate

0.610.670.63Risedronate

HipNon-vertebralVertebral

* One Trial only

6

4

2

0

Rel

ativ

e ris

kR

elat

ive

risk

<2.5 mg/day<2.5 mg/day 2.52.5––7.5 mg/day7.5 mg/day > 7.5 mg/day> 7.5 mg/day

HipHipSpineSpine

Daily Oral Glucocorticosteroid DoseDaily Oral Glucocorticosteroid Dose

van Staa et al, J. Bone and Mineral Res. 2000;15(6);993-1000

Oral Glucocorticosteroid Dose Strongly Correlates to Fracture Risk

Oral Glucocorticosteroid Dose Strongly Oral Glucocorticosteroid Dose Strongly Correlates to Fracture RiskCorrelates to Fracture Risk

RCP/ Bone & Tooth Soc/ NOS 02

• If commitment or exposure to steroids >/ = 3 months, general measures for all

• If age>65 or prior fragility fracture, commence bisphosphonate or other agent

• If age<65 and no fracture, measure BMD and if T-score </= -1.5 commence bisphosphonate or other agent

• Any dose of oral steroid, inhaled steroid > 1mg a day

• Assumes DXA quickly available

Paget’s DiseasePaget’s Disease

Paget‘s Disease: FeaturesPaget‘s Disease: Features

• Radiological: Plain radiographs, scintigraphs

• Laboratory analysis: e.g. total SAP

• General: Under-diagnosed, under-treated and sub-optimally managed

• Early diagnosis may yield better treatment outcome and prevention of complications

Diagnosis

• Asymptomatic stage: Silent but progressing

• Symptomatic stage:

• 5%-10% of all patients are symptomatic

• Most frequent symptoms and complications: Pain, bone deformities, osteoarthritis, fractures, nerve compression

Clinical presentation

• Increased bone turnover triggered by osteoclast hyperactivity

• SAP normalization needed to achieve longer remission periodPathophysiology