Rheumatology
Seán Keenan
2022
,Back Pain
Description
Often self-limiting but can be sign of sinister cause such as malignancy, infection or inflammatory disease. If presenting
with red-flag signs, further investigations are required
Back Pain in General
Presentation Investigations
- Spine: Assess Forward/Lateral Flexion; Extension - General: FBC; ESR; CRP
- NB: Schober’s test - Paget’s: U&E; ALP
- Sacrum: Assess sacroiliitis - Myeloma: Electrophoresis; Bence-Jones in urine
- Nerve: Limb sensation/power; Nerve root pain - X-ray: Bony abnormalities or fractures
- NB: Straight leg raise; Femoral stretch tests - MRI: Prolapse; Cord compression; Various lesions
Causes Management
- 15-30 YO: Prolapsed disc; Trauma; AS; Pregnancy - Neuro Sx: Urgent referral (see below)
- 30-50 YO: Prolapsed disc; Malignancy - Thoracic Pain: Urgent referral
- >50 YO: Paget’s disease; Myeloma; Spinal stenosis - Non-specific Sx: Paracetamol ± NSAIDs ± Codeine
- Rare: Cauda equina tumour; Psoas abscess; Pott’s - Alternative: Consider low dose neuropathic meds
Red Flag Symptoms Associated with Back Pain
Aged <20 YO or >55 YO Worse pain on being supine Thoracic back pain Sphincter disturbance
Acute onset in elderly people Fever + Night sweats + ↓ Weight Morning stiffness Current or recent infection
Constant / Progressive pain Hx of malignancy Bilateral or alternating leg pain Immunosuppression (e.g. steroid/HIV)
Nocturnal pain Abdominal mass Neurological disturbance (sciatica) Leg claudication
Neurological Emergencies
Description - Acute cord compression
- Acute cauda equina compression o Pain: Bilateral pain
o Pain: Alternating or bilateral root pain in legs o LMN: Occur at level of compression
o Sensation: Saddle anaesthesia (perianal) o UMN: Occur below level of compression
o Tone: Loss of anal tone on PR o Tone: Sphincter disturbance
o NB: Bladder ± Bowel incontinence
- Immediate urgency treatment
o Disc protrusions: Laminectomy
o Tumours: Radiotherapy
o Abscesses: Decompression
Nerve Root Lesions
Nerve root Pain Weakness Refex affected
L2 Across upper thigh Hip flexion and adduction Nil
Hip adduction
L3 Across lower thigh Knee jerk
Knee extension
Knee extension
L4 Across knee to medial malleolus Foot inversion Knee jerk
Dorsiflexion
Knee extension
L4 Across knee to medial malleolus Foot inversion Knee jerk
Dorsiflexion
Hip extenion and abduction
L5 Lateral shin to dorsum of foot and great toe Knee flexion Great toe jerk
Foot and great toe dorsiflexion
Knee flexion
S1 Posterior cald to lateral foot and little toe Foot and toe plantar flexion Ankle jerk
Foot eversion
, MRI showing disc herniation and spinal cord compression
Seán Keenan
2022
,Back Pain
Description
Often self-limiting but can be sign of sinister cause such as malignancy, infection or inflammatory disease. If presenting
with red-flag signs, further investigations are required
Back Pain in General
Presentation Investigations
- Spine: Assess Forward/Lateral Flexion; Extension - General: FBC; ESR; CRP
- NB: Schober’s test - Paget’s: U&E; ALP
- Sacrum: Assess sacroiliitis - Myeloma: Electrophoresis; Bence-Jones in urine
- Nerve: Limb sensation/power; Nerve root pain - X-ray: Bony abnormalities or fractures
- NB: Straight leg raise; Femoral stretch tests - MRI: Prolapse; Cord compression; Various lesions
Causes Management
- 15-30 YO: Prolapsed disc; Trauma; AS; Pregnancy - Neuro Sx: Urgent referral (see below)
- 30-50 YO: Prolapsed disc; Malignancy - Thoracic Pain: Urgent referral
- >50 YO: Paget’s disease; Myeloma; Spinal stenosis - Non-specific Sx: Paracetamol ± NSAIDs ± Codeine
- Rare: Cauda equina tumour; Psoas abscess; Pott’s - Alternative: Consider low dose neuropathic meds
Red Flag Symptoms Associated with Back Pain
Aged <20 YO or >55 YO Worse pain on being supine Thoracic back pain Sphincter disturbance
Acute onset in elderly people Fever + Night sweats + ↓ Weight Morning stiffness Current or recent infection
Constant / Progressive pain Hx of malignancy Bilateral or alternating leg pain Immunosuppression (e.g. steroid/HIV)
Nocturnal pain Abdominal mass Neurological disturbance (sciatica) Leg claudication
Neurological Emergencies
Description - Acute cord compression
- Acute cauda equina compression o Pain: Bilateral pain
o Pain: Alternating or bilateral root pain in legs o LMN: Occur at level of compression
o Sensation: Saddle anaesthesia (perianal) o UMN: Occur below level of compression
o Tone: Loss of anal tone on PR o Tone: Sphincter disturbance
o NB: Bladder ± Bowel incontinence
- Immediate urgency treatment
o Disc protrusions: Laminectomy
o Tumours: Radiotherapy
o Abscesses: Decompression
Nerve Root Lesions
Nerve root Pain Weakness Refex affected
L2 Across upper thigh Hip flexion and adduction Nil
Hip adduction
L3 Across lower thigh Knee jerk
Knee extension
Knee extension
L4 Across knee to medial malleolus Foot inversion Knee jerk
Dorsiflexion
Knee extension
L4 Across knee to medial malleolus Foot inversion Knee jerk
Dorsiflexion
Hip extenion and abduction
L5 Lateral shin to dorsum of foot and great toe Knee flexion Great toe jerk
Foot and great toe dorsiflexion
Knee flexion
S1 Posterior cald to lateral foot and little toe Foot and toe plantar flexion Ankle jerk
Foot eversion
, MRI showing disc herniation and spinal cord compression
