Dr Raj Sengupta

Low Back pain

• 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

Low Back pain

• 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

• 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

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

Ankylosing Spondylitis

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

• 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

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

Role of MRI

Axial Spondyloarthritis

Case presentation

• 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

• 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

RS clinic

• IBP symptoms

• MRI reviewed

• Correct MRI requested – Diagnosis made

• Patient frustrated and delay in diagnosis

GP Inflammatory Back Pain Pathway

Back pain

Inflammatory back pain

Xray pelvis

Sacroiliitis on xray Normal

HLA B27 positiveRefer to me

• 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