Rheumatology E-learning

University of Szeged

Department of Rheumatology and Immunology

Degenerative disorders of the spine I.

Pathogenesis: The weakening of the intervertebral cartilagineous discs

○ Gradually, with increasing age, due to a slow degeneration and the loss of water - discopathy

○ Suddenly, after an inappropriate movement – protrusion, orherniation of the disc

The link between the two adjacent vertebrae becomesunstable – the vertebrae dyslocate

Mechanical irritation – inflammation in the adjacent softtissues

Increased muscle tone – myalgia, muscle spasm

The „wearing” of the vertebrae – the calcification of thesurrounding bone surfaces – spondylosis

The origin of pain: muscle tension, spasm, and local irritative inflammation → treatment targets: physiotherapy, gymnastics, anti-inflammatory drugs, myorelaxants

Cervical spondylosis

Disc herniation

From: spienuniverse.com

MRI images of herniated discs

From: columbiaspine.org From: saspine.org

Degenerative disorders of the spine II.

Symptoms:

Pain – increased by physical exertion, eased by rest

Decreased range of motion

The sensation of muscle strain

In case of a nerve-root irritation: lumbo-ischialgia, cervico-brachialgia – pain referring to the lower of the upper limb, + numbness, loss of sensation, paresis, decreased reflexes may be present!

Sciatica – pain due to a compression on

the sciatic nerve

Degenerative disorders of the spine III.

Treatment: Acute low back pain (Lumbago acuta):

○ Sparing, rest (few days only), analgesics (paracetamol, brief courses of NSAIDs), muscle relaxant, early rehabilitation

Disc herniation○ Initially: as above

○ In case of paresis, sphincter-innervation abnormality, therapy-resistant pain: CT or MRI, neurosurgical intervention may be necessary depending upon the clinical picture and the imaging results. Cauda syndrome, paresis: indication of urgent operation!

Chronic spinal pain○ The learning of a spine-sparing lifestyle

○ Regular gymnastics, swimming

○ Intermittent physiotherapy

Septic spondylodiscitis

Inflammation of the vertebrae (always twoadjacent vertebrae) + the disc between them

Origin: haematogenic spreading – search forprevious potential bacterial entry (toothextraction, urinary tract infection, enteritis, gonococcal infection, diabetic leg ulcer, previousinvasive interventions, operations)

Usually immunocompromised persons (elderly, diabetes mellitus, chronic renal failure, immunosuppressive th) are affected

Septic spondylodiscitis – conventional radiographic image:

-The destruction and compression of two adjacent vertebrae

-Adjacent end-plates become fragmented, uneven and eroded

-Damage to the intervertebrate disc → disc space narrowing, fusion of two vertebrae may ensue

Native T1-weighted: The Th vertebra No 9 and 10 aredestroyed, in their remainingparts the signal intensity is diffusely reduced, and theadjacent end-plates havedisappeared.Contrast-enhanced T1-weighted: contrast accumulation in thesevertebrae and theintervertebrate space. Paravertebral soft tissue mass, causing spinal cord compression.

Septic spondylodiscitis

Pain at rest (usually strong, acute but not abrupt onset), increased laboratory inflammatory paremeters (+/-neurological deficits)

X-ray: The destruction and compression of two adjacent vertebrae, with end-plates becoming fragmented, uneven and eroded. Vertebral fusion (block-vertebrae) may arise.

MRI confirms the diagnosis and adds further details: abscess formation, soft tissue changes, tumour vs. septic process.

CT-guided biopsy and culture sampling differentiatesbetween tumour or abscess, and identifies the pathogen

Th: conservative (antibiotic, bed rest), surgery: in theevent of instability, neurological symptoms, therapy-resistance, spinal cord compression, psoas abscess

Tendinitis, tendovaginitis, enthesitis

• Localised pain

• Swelling

• Tenderness localised to tendons or tendinealinsertions

• Pain eased by rest and markedly provokedby the movement of the respective muscle

• Diagnosis: – Direct tenderness

– Pain is provoked by the movement of the involvedmuscle against resistance

Enthesitis – Achilles tendon

Reactive arthritis - enthesitis

Lateral epicondylitis of the humerus

(tennis elbow)

Tendovaginitis (tenosynovitis) de Quervain

Rotator cuff injury – „middle arch sign”

Plantar fasciitis

Treatment: Rest

Topical cold (ice)

Appropriate exercise, stretching, muscle strengthening

NSAID

Insole, appropriate shoe for everyday and for sports, if spur: ring (sandwich) insole

Steroid injection to the surrounding of the enthesis (risk of rupture)

Bursitis

Inflammation of the periarticular bursae

Symptoms: pain, direct tenderness, mass if superficial. The pain is not always associated with movement

Presentation: elbow (olecranon), shoulder (subacromial), back (subscapular), hip (trochanter), buttock (ischiadic), around the knee (praepatellar, semimembranous, semitendinous), heel (Achilles)

Chronic gouty olecranon bursitis

Chronic gouty (tophaceous) olecranon

bursitis

Trochanteric bursitis

• Pain at the hip region, thatincreases when lying on theinvolved side

• Hip movements are normal

• Direct pressure on the greatertrochanter when the patient lieson the side triggers the pain

• Ultrasound or – in case of calcification – X-ray confirmsthe diagnosis

Prepatellar bursitis

Circumscript, tender

swelling frontal to the patella

or below it. It ballots and

tender on direct pressure

Cause: kneeing („maiden-

knee, friar’s knee”),

overload (running,

squatting), quadriceps

weakness

Neuralgias, nerve compression

syndromes (tunnel syndromes)

Symptom: burning, needle-and-pin type pain specifically at the localisation of a nerve. Stronger at night and at rest, often exacerbated by touch (contact with blanket or clothing)

Hypaesthesia (reduced sensation), paraesthesia (numbness)

If the motor component is involved: muscle weakness or wasting

Deep tendon reflexes are lost or diminished

Compression to specific nerve points (Tinel sign) causes a lightning-type acute, sharp pain that follows the course of the nerve

Differential dg: root compression (herniated disc), myelopathy, autoimmune neuritis, zooster (shingles), diabetic neuropathy

Carpal tunnel syndrome

Wrist pain radiating tothe I-III fingers, causingnumbness and sensorydysfunction

In more severe cases: anaesthesia, weaknessof the flexion of fingers, thenar atrophy

Carpal tunnel syndrome– Tinel sign

Cubital tunnel syndrome

Compression of the ulnar

nerve at the medial

aspect of the elbow

Symptom: pain,

numbness, hypaesthesia

in the IV-V. fingers,

weakness of the flexion of

the IV-V. finger

Scalenus syndrome

Nerve (brachial plexus) entrapment inthe gap between the clavicle and thetwo scalenus muscles

Causes: cervical rib, hypertrophicscalenus muscles (overuse), pressure(e.g. playing violine)

Symptoms: pain, numbness, loss of sensation at the lateral part of the hand, hypothenar muscle weakness and atrophy

Diagnosis: Adson test

Piriformis syndrome

Causes: muscle spasm, hyperlordotic lumbar spine, injury (fall at buttock), haematoma

Symptoms: ischialgia, inability to sit

Differentiation among the causes of

ischialgia

Laségue-test positivity: spinal root origin

Pain provoked at adduction of hip and crossing of the legs: piriformis syndrome

Femoral neuralgia

• Femoral nerve laesion, usually inthe femoral canal

• Causes: hip osteoarthrosis, lumbarspine deformity, overuse

• Symptoms: pain at the anterioraspect of the thigh and the knee, numbness at this region, quadricepsmuscle weakness, abnormal gait, decreased or lost knee jerk reflex

• Direct pressure on the femoralnerve is positive

• Femoral sign: in prone position: flexion of the knee causes a sharp, neuralgiform pain at the anterioraspect of the thigh

Femoral neuralgia – local injection

treatment

Femoral nerve punction site: 2 cm lateral from the femoral artery

Medial tarsal tunnel syndrome

Compression of the tibialis posterior nerve

Cause: flat foot, valgus deformity or inflammation of the ankle, exostosis, irritation by shoe

Symptoms: pain and numbness in the sole, weakness of plantar muscles (short toe flexors)

Tinel sign

Lateral tarsal tunnel syndrome

Compression of the suralis

nerve

Cause: inflammation or injury

of the lateral ankle ligaments

or peroneal tendons.

Symptoms: burning pain in

the lateral part of the foot, the

heel and in the 4th and 5th

toes

Tinel sign positive

Metatarsal tunnel syndrome

Compression of nerves going to the toes at the level of the metatarsal heads

Causes: flat transverse arch, hammer toe, irritation by shoe, overload (obesity, excessive running, etc.)

Symptoms: pain and numbness in the facing (adjacent) aspects of two neighbouring toes. Compression of the MTP line provokes the pain

Complication: if the irritation is durable: Morton’s neuroma may develop, which leads to very intense pain in the 2nd, 3rd and 4th toes

Treatment: injection, insole, operation

Non-pharmacological treatment of

knee osteoartritis Strongly recommended:

Trained exercise

Subaqual or „dry”

If obese: weight loss

„Weakly” recommended: „Self-management programmes” – psychosocial

support

Thermotherapy

Manualtherapy - chyropractice

Patella bandage

Tai chi

Walking aids

Medial compartment: laterally elevated insole

Lateral compartment: medially elevated insole

Knee osteoarthritis –

pharmacological therapy Conditionally recommended:

Paracetamol (full-dose) under medical supervision

Oral or topical NSAID○ Over 75 years: almost always topical NSAID

○ GVR < 30 ml/min: contraindicated!

Tramadol, duloxetin

Intraarticular corticosteroid or hialuronic acid

Chondroitin sulphate… - not supported

Prosthesis implantation

Opioids

TENS if prosthesis is notfeasible

acupuncture

Hand osteoarthritis – non-

pharmacological therapies

Only „mild” recommendations

Learning of joint-protective techniques

Assessment of functions necessary for everyday

acitivites

Provision with aids

1st CMC osteoarthritis – immobilizing (resting)

splint

Thermotherapy

Hand osteoarthritis – drug therapy

Topical or oral NSAID

Topical capsaicin

Tramadol

„Conditionally” not recommended: opioids, intraarticular injections

I. CMC joint – if not required by the patient –neither corticosteroid, nor hialuronic acid is recommended

If given by the treating physician: no preference to either one

Erosive or inflammed osteoarthritis: „conditionally” not recommended: methotrexate, sulfasalazin. Hydroxychloroquin: no consensus

Non-steroidal antiinflammatory drugs

Ciclo-oxigenase inhibition

Reduces the production of prostaglandins

Fast, but moderate efficacy

Indomethacin, diclofenac, naproxen,

piroxicam – non-selective

Etoricoxib, nimesulid, meloxicam –

cyclooxigenase (COX)-2 selective

Inhibition of ciclooxigenase-1 and -2

Indications of NSAIDs

Acute inflammation of mild-moderate severity Inflamed osteoarthrosis, soft-tissue rheumatism,

overuse-induced local inflammation

Gouty attack

Spondylarthropathies

RA, SLE… rarely (because they are not effectiveenough, and these diseases require long-termimmunosuppression)

Dental painful inflammation, pleuritis, dysmenorrhaea

As adjuvant: urinary stone attack, tumour

Risks of NSAIDs

• Gastrointestinal mucosal damage– Depends on the ratio of COX-1/COX-2 inhibition of the

agent

– Chemical characteristics (pH)

– Preparation, route of administration (parenteral, suppository, encapsulated oral delivery)

• Peptic ulcer, erosive gastritis, GI bleeding (highmortality!)

• High-risk groups: age > 50 years, prior peptic ulcer, concomitant aspirin, corticosteroid, anticoagulant, alcohol, nicotine abuse, chronic stress

• If even the smallest risk is present: simultaneousPPI treatment, or even contraindicated

Risks of NSAIDs

Impairment of renal circulation

Kidney function impairment, acute renal failure

Oedema

Hypertension

High risk patients: age > 60 years, diabetes

mellitus, renal artery stenosis, concomitant ACE-

inhibitor, ARB or diuretic, dehydration – in these

situations, the renal perfusion is extremely

prostaglandin-dependent

No specific treatment, only prevention

Risks of NSAIDs

Arterial thrombosis

Inhibition of cyclooxigenase

Increased risk of myocardium infarction duringNSAID therapy

Highest risk: COX-2 selective NSAIDs

Liver function impairment

Summary: NSAID treatment should be givenonly in real indication, for a maximum of 10 days, and typically in PPI protection. In manyhigh-risk cases, NSAIDs are contraindicated!