🤔 MEDIUM

One of the most common presentations to General Practice, see whether you have broken the back of this topic!

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Approach to the patient with Back Pain

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Question 1

Stem 1, question 1 of 4

Saddiq, a 55 year old man, presents to his GP with a 3 week history of lower back pain.

Which of the following must be excluded in someone presenting with back pain?
A
Disc herniation
B
Lumbar spine stenosis
C
Ankylosing spondylitis
D
Cauda equina syndrome
E
Spondylolisthesis
Question 1 Explanation: 
Hopefully this is a nice question to ease you in. Cauda equina syndrome is where the caudal equina bundle of spinal nerves become compressed and requires emergency MRI and may require urgent surgical decompression. This must be excluded in all patients presenting with back pain. The main signs are saddle area anaesthesia, incontinence or retention of urine or faeces, reduced anal tone, paralysis and or sensory loss.
Question 2

Stem 1, question 2 of 4

Which structure extends between the lamina of adjacent vertebrae?
A
Intertransverse ligament
B
Nucleus pulposus
C
Supraspinous ligament
D
Ligamentum flavum
E
Interspinous ligament
Question 2 Explanation: 
The ligamentum flavum extends between the lamina of adjacent vertebrae. The intertranserve ligament extends between the transverse processes, interspinous and supraspinous ligaments attach between the spinous processes. The nucleus pulposus is the jelly like component of the vertebral disc.
Question 3

Stem 1, question 3 of 4

Saddiq walked with a forward flexed gait and on examination has diminished pulses and mottled skin of his legs. What is the most likely diagnosis for his back pain?
A
Mechanical back pain
B
Disc herniation
C
Spinal infection
D
Sciatica
E
Lumbar spin stenosis
Question 3 Explanation: 
The question tests your understanding of examination findings in back pain differentials. Walking with a forward flexed gait accompanied with diminished pulses and skin changes such as mottling, thinning and shininess indicating vascular claudication in lumbar spine stenosis. Lumbar spine stenos is a degenerative condition of the lumbar spine that results in narrowing of the spinal canal. BMJ best practice has great resources on examination findings in back pain on the website.
Question 4

Stem 1, question 4 of 4

Saddiq is referred for surgical decompression of his stenosis and is given corticosteroids. Which of the following is a corticosteroid?
A
Atropine
B
Prednisolone
C
Fomoterol
D
Tolcapone
E
Ketorolac
Question 4 Explanation: 
Prednisolone is a glucocorticoid steroid that is used to reduce inflammation. Atropine is a antimuscarinic. Fomoterol is a beta 2 adrenergic agonist, Tolcapone is a COMT inhibitor, ketorolac is an intravenous NSAID.
Question 5

Stem 2, question 1 of 6

Edith, an 84 year old female, presents to the emergency department with back pain following a fall while out shopping

What would be an appropriate initial investigation to perform?
A
CT spine
B
Blood cultures
C
Plain X-ray of spine
D
MRI of spine
E
Blood alcohol level
Question 5 Explanation: 
Edith has a number of risk factors for a vertebral fracture: increasing age and high likelihood of osteoporosis (remember that post-menopausal people are at high risk of osteoporosis due to the drop in oestrogen). Therefore the most appropriate initial investigation would be a plan x-ray of the spine.
Question 6

Stem 2, question 2 of 6

Osteomyelitis is another cause of back pain, which of the following is not a risk factor for this condition?
A
Smoking
B
Periodontitis
C
Intravenous drug use
D
Surgical contamination
E
History of penetrating injury around the spine
Question 6 Explanation: 
Although smoking is a risk factor for many diseases, it is not a recognised risk factor for osteomyelitis. All the other answer options are risk factors for osteomyelitis.
Question 7

Stem 2, question 3 of 6

Edith is diagnosed with a vertebral fracture and given codeine. What class of drug does codeine interact with?
A
Anti-muscarinics
B
Beta blockers
C
Dopamine depleting drugs
D
H2 receptor antagonists
E
Sedatives
Question 7 Explanation: 
Codeine is a weak opioid analgesic meaning it stimulates the opioid receptors and can result in sedative effects. Both codeine and sedatives have depressive effects on the central nervous system meaning there is more likely to result in impaired consciousness. The British National Formulary is a greta resource to look at for drug interactions
Question 8

Stem 2, question 4 of 6

Back pain is is a leading cause of disability worldwide. What is the social model definition of disability?
A
Bodily, mental or intellectual limitation or condition
B
Loss or limitation of opportunities to take part in society on an equal basis
C
An individual deficit within an individual
D
The outcome of complex interactions between impairments and the social, environmental and cultural contexts
E
A physical or mental impairment and the impairment has a substantial and long-term adverse effect on the individuals ability to carry out normal day to day activities
Question 8 Explanation: 
Ahh SocPop returns! There are a number of models of disability: Medical, Social and Interactional. The Social Model explains that individuals may have an impairment (answer option 1), but that disability is the inability to take part in society on an equal basis, an example of this is a lack of widen doorways and ramps in a building.
Question 9

Stem 2, question 5 of 6

Back pain can also be caused by cancer metastases to the spinal column. Which of the following is not a cancer likely to metastasise to the spinal column?
A
Brain
B
Lung
C
Prostate
D
Breast
E
Thyroid
Question 9 Explanation: 
Cancers of the brain are less likely to metastasise to the spinal column whereas lung, prostate, breast, thyroid and renal cancers are most likely to metastasise to the spinal column
Question 10

Stem 2, question 6 of 6

Whilst at the GP Edith sees an advert about a change in the law around organ donation. What is the current organ donation system in England?
A
Opt out system
B
Opt in system
C
Living donations only
D
Donation after neurological death
E
Donation after cardiac death
Question 10 Explanation: 
England in May 2020 moved to an Opt out system of organ donation. This means to be in favour of organ donation is the default, but people are still free to opt out of that choice.
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