Back pain

Question 1

back pain red flags

Answer 1

age <20 or >50
pain at night, progressive or constant pain, pain lying flat
alcohol or drug use
systemic symptoms: weight loss, reduced appetite, fever, night sweats - cancer
neurological - weakness, numbness (Saddle anaesthesia)
bladder or bowel symptoms
history of cancer
significant trauma
pain in thoracic spine

Question 2

presentation of cauda equina

Answer 2

numbness, weakness, gait difficulty
bladder or bowel symptoms - incontinence or retention
saddle anaesthesia
bilateral leg weakness

Question 3

management of suspected cauda equina

Answer 3

send to A and E
urgent MRI
decompression surgery

Question 4

examination in back pain

Answer 4

spinal exam
full neurological exam if any signs of cauda equina or neurological involvement - UMN e.g.cord, LMN e.g. caudal equina or root
Schobers
temperature
lymphadenopathy
localised tenderness: fracture, discitis or malignancy
DRE!!! - tone, power, sensation - reduced sensation and tone in cauda equina

Question 5

management for lower back pain and sciatica

Answer 5

warn about red flags
encourage to return to normal activities and avoid bed rest (> 2 days isn't recommended)
exercise 
avoid precipitants
physiotherapy and advised to mobilise
analgesia to control pain
use heat and ice 
mobility devices
environment modifications
weight loss
consider psychological therapy 
return to work programmes

Question 6

goals of rehab in patients with spinal pain

Answer 6

reduced spinal related pain
improve strength, flexibility, lifting capacity and endurance
minimise spine related disability
normalise activities of daily living
return to work and vocational activities

Question 7

prognosis of lower back pain

Answer 7

most recover by 6-12 weeks
over 50% will experience another episode in one year
patients who fail to recover by 4 months are more likely to progress to long term chronic back pain

Question 8

presentation of prolapsed disc, sciatic pain:

Answer 8

shooting pain down one leg
reduced straight leg raising on affected side
positive sciatic stretch on affected side
leg symptoms are predominant symptoms and neurological signs are found in a specific nerve root distribution
MRI preferred imaging to confim diagnosis
common in patients under 50 (spinal stenosis more common >60)

Question 9

management of a prolapsed disc

Answer 9

physiotherapist, OT, psychotherapy
address complex issues related to different pain behaviours
psychological barriers to treatment
prescribe different forms of medication called pain modifying medication e.g. amitriptyline, gabapentin
topical analgesics

Question 10

differentials of back pain

Answer 10

facet back pain
fracture
cancer
cauda equina
mechanical
trauma and insufficiency fractures
rheumatological

Question 11

when should you do a X-ray in back pain

Answer 11

trauma
fracture
degenerative changes

Question 12

pharmacological management of lower back pain

Answer 12

consider NSAIDs
dont offer paracetamol alone
consider weak opioids with or without paracetamol if NSAIDs contraindicated
don’t offer SSRI, SNRI or TCA, or anticonvulsants for managing low back pain

sciatic pain: amitriptyline, gabapentin, pregablin initial treatment for neuropathic pain