Week 8- Back Pain

Question 1

What are some facts about back pain?

Answer 1

One of the most common complaints in humanity
65-80% have back pain at some point
Most common cause to limit physical activity after age 45
Increases with age
The majority have no pathoanatomic cause

Question 2

What does the psoas muscle do?

Answer 2

Hip flexion
Hip internal rotation
Hip adduction
Rotate lumbar spine

Question 3

What leads to shortened psoas muscle?

Answer 3

Sitting

Question 4

What symptoms favour an inflammatory cause of back pain?

Answer 4

Stiffness worse after sitting or lying, sudden onset of ankle swelling

Question 5

What are some causes of back pain?

Answer 5

Ankylosing spondylitis
Mechanical back pain (remember most do not have a clear pathoanatomic cause)- lumbar radiculopathy a.k.a sciatica, osteoarthritis
Osteoporotic vertebral fracture
Spinal cord compression, cauda equina syndrome

Question 6

What are some symptoms of ankylosing spondylitis?

Answer 6

Back pain
Insidious onset
Improved by exercise, worsens with rest
Pain at night
Pain in the buttocks
Hip pain

Question 7

What are the ways ankylosing spondylitis is treated?

Answer 7

Patient education- exercise and posture training programme
Patient support groups
Stop smoking
Physiotherapy
NSAIDs

Question 8

What parts of the body can ankylosing spondylitis affect?

Answer 8

Eyes (uveitis)
Shoulders
Gut (IBD)
Sacroiliac joints
Skin (psoriasis)
Knees
Heels

Question 9

Lumbar Radiculopathy is most commonly due to…

Answer 9

Disc herniation
Spondylosis due to degenerative osteoarthritis

Question 10

Why can the presentation of Lumbar Radiculopathy vary?

Answer 10

Presentation will vary depending on which nerve root is involved
This is because each nerve root provides sensation to part of the skin (dermatome) and provides innervation to certain muscles (myotome)

Question 11

What is the most common type of Lumbar Radiculopathy?

Answer 11

L5 Radiculopathy

Question 12

What are the symptoms of L5 Radiculopathy?

Answer 12

Back pain radiating down the lateral aspect ofthe leg into the foot
Weakness associated with foot dorsiflexion, toe extension, and foot inversion and eversion

Question 13

How is Lumbar Radiculopathy diagnosed?

Answer 13

It is a clinical diagnosis but need to watch out for other causes or red flags

Question 14

What are some red flags when a patient presents with back pain?

Answer 14

Progressive or severe motor deficit
Suspected or known cancer (could be due to metastases)
Suspected infection (could be an abscess)
Urinary retention
Urinary or faecal incontinence
Numbness round the anus (saddle anaesthesia), loss of anal sphincter tone
Bilateral symptoms

Question 15

What is the treatment of radiculopathy?

Answer 15

Exercise- keep active, physiotherapy referral
CBT
NSAIDs
Avoid opiates especially for chronic pain

Question 16

Where are osteoporotic vertebral fractures most likely?

Answer 16

Lumbar or thoracic spine

Question 17

How suddenly to osteoporotic vertebral fractures occur?

Answer 17

Can happen acutely or over time

Question 18

How quickly does pain resolve with an osteoporotic vertebral fracture?

Answer 18

4-6 weeks

Question 19

What does an osteoporotic vertebral fracture lead to?

Answer 19

Loss of height and may cause kyphosis

Question 20

What does the treatment for osteoporotic vertebral fractures involve?

Answer 20

Acute treatment-
Analgesia: paracetamol, NSAIDs, short term use of opiates permissible (<4weeks)
Assess for osteoporosis-
DEXA scan
Treatment of suspected osteoporosis-
Adequate calcium and vitamin D, bisphosphonates

Question 21

What causes cauda equina syndrome?

Answer 21

Central disc protrusion
Malignancy- cancer spread to vertebra and compress lumbosacral nerve roots
Prostate, breast and lung are most common but any malignancy could cause it

Question 22

What are the symptoms of caudal equina?

Answer 22

Back pain is usually first followed by progressive neurological signs including lower limb weakness, bowel and bladder dysfunction including urinary retention and sensory loss (often less prominent)

Question 23

What does the treatment of cauda equina syndrome involve?

Answer 23

Cauda equina syndrome is a medical emergency
Urgent referral and MR scan spine
Neurosurgical intervention may be required