4th Year Rheumatology Lecture 2 The Spine and Metabolic Bone Disease

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4th Year RheumatologyLecture 2The Spine and
Metabolic Bone Disease
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Spine

• Components
• Cervical
• Thoracic
• Lumbar
• Sacrcoccygeal

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Spinal pain

• Mechanical
• Inflammatory
• Due to metabolic bone disease
• Extra spinal cause

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Mechanical Spinal Pain (causes)

• Intervertebral disc prolapse
• Spondylosis
• Spondylolisthesis

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Inflammatory spinal pain (causes)

• Ankylosing spondylitis
• Spondylitis related to
• psoriasis
• inflammatory bowel disease
• Reiters syndrome
• Infection
• Neoplasm

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Extaspinal causes of back pain

• Leaking aortic aneurysm
• Pelvic pathology
• Retroperitoneal pathology

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Spinal pain emergencies

• Leaking aortic aneurysm
• Spinal cord compression

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Inflammatory Vs mechanical pain

• Inflammatory
• slow onset
• worse with rest
• prolonged early morning stiffness
• Mechanical
• more rapid onset
• worse with activity and better with rest
• no significant early morning stiffness

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Ankylosing spondylitis

• Chronic systemic inflammatory rheumatic disorder
  with prediliction for axial skeleton
• Sacroilitis
• Strong genetic predispostion for HLA B27

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Ankylosing spondylitis (clinical features)

• Chronic inflammatory back pain
• Limitation of spinal mobility
• Characteristic radiological findings
• Symptomatic relief from anti-inflammatory drugs

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Ankylosing Spondylitis

• Extra articular manifestations
• acute anterior uveitis
• aortic incompetence, conduction defects etc
• apical pulmonary fibrosis

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Ankylosing spondylitis

• Investigations
• Fbc
• ESR, CRP
• Immunoglobulins

• Imaging
• Plain Xrays
• Bone scan
• CT scan
• MRI

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Ankylosing spondylitis

• Management
• General health
• Physical treatment and education
• drug treatment
• NSAID
• Second line drugs (occasionally)

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Metabolic bone disease

• Osteoporosis
• Osteomalacia
• Pagets disease

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Osteoporosis

• Risk Factors
• family history
• Slender body build
• Fair skin
• Early menopause
• Sedentary life
• Low calcium intake

• Cigarette smoking
• Excessive alcohol
• Excessive caffeine
• steroid therapy
• thyroid disease

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Osteoporosis

• Other conditions to consider
• Osteomalacia
• Osteogenesis imperfecta
• Hyperparathyroidism
• Hyperthyroidism
• Cushings syndrome
• Mulitple myeloma
• Renal failure

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Osteoporosis (presentation)

• Back pain
• Routine X-rays
• Screening high risk patients
• Fractures

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Osteoporosis (management)

• Exercise
• Calcium
• Vit D
• Oestrogen
• Cacitionin
• Bisphosponates

• Fluoride
• Calitriol
• Androgens

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Osteomalacia

• Vit D defficiency
• low intake plus inadequate sunlight exposure
• malabsorption
• Abnormal vit D metabolism
• Liver disease
• Renal disease
• Drugs(anticonvulsants)
• Hypophosphatesia
• Low intake

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Ostemalacia (clincial manifestation)

• Bone pain
• Proximal muscle weakness
• Low Calcium and phosphate with raised ALP
• Looser zone in X-rays

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Pagets Disease

• Disease of bone remodelling
• osteoclast mediated bone resorption followed by
  new bone formation
• Disorganised mosaic pattern bone with increased
  vascularity and fibrosis
• Cause unknown ?virus (paramyxovirus and canine
  distemper)
• More common in caucasian
• Menwomen ratio 32

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Pagets Disease (clinical manifestation)

• Bone pain
• Joint pain
• Deformity
• Spontaneous fractures

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Pagets Disease (complications)

• Fractures
• Deafness
• Nerve entrapment
• Spinal stenosis
• Cardiac failure
• Osteogenic sarcoma
• Hypercalcemia

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Pagets Disease (investigations)

• Serum alk phosphate
• Urinary hydroxy proline and pyridinoline cross
  links
• X-rays
• cortical thinkeningo
• steolytic, osteiocslerotic and mixed leisions
• osteoporosis circumcripta
• bone scan

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Pagets Disease (treatment)

• Calcitonin
• Bisphosphonates
• Disodium etidronate
• Pamidronate