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 reflexes L4: knee jerk L5: dorsiflexion, medial sensation S1: 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) Undifferentiated SpA Juvenile chronic arthritis Reactivearthritis Ankylosing spondylitis Psoriaticarthritis Arthritis / spondylitis associated with IBD Linden VD. In: Kelley’s Textbook of Rheumatology. Ankylosing Spondylitis. 8 th ed Sieper 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 present Sieper et al. Annals Rheumatic Diseases 2009;68: Inflammatory Back pain

Ankylosing Spondylitis Reactive SpAIBD/ PsSpAUSpA 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 xrayNormal 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