What symptoms are suggestive of cauda equina syndrome?
- Numbness, weakness, gait difficulty
- Bladder or bowel symptoms - retention or incontinence
- Saddle anaesthesia
- Bilateral leg weakness
In what medical conditions can pain be referred to the back?
- Pyelonephritis - dysuria, frequency
- Leaking AAA - dizziness, vascular risk factors
- Peptic ulcer disease - epigastric pain
- Acute pancreatitis
- Aortic dissection - radiates from heart through to back
What questions do you want to ask in a back pain history?
- Site, quality, nature of pain and referral
- Variation throughout the day - early morning stiffness could indicate inflammatory e.g. ankylosing spondylitis
- Onset: acute vs insidious, trauma vs degenerative
- Exacerbating/relieving factors - night pain should raise concern for malignancy/infection
What are red flags of spinal pain?
- Age <20yrs or >50yrs
- Systemic symptoms: fever, weight loss, fatigue, night sweats, reduced appetite
- Night pain, progressive or constant pain, pain lying flat
- Neurology - weakness, numbness, bladder or bowel symptoms
- Hx of cancer
- Significant trauma
- Immunosuppression
What should be seen in the inspection part of a spinal examination?
- Observe patient’s as they walk into clinic e.g. foot drop, abnormal posturing
- Observe when undressing to see how easily and freely they move
- Inspection should look for obvious deformity e.g. scoliosis, skin marking
- Overall alignment - assessed by line from C7.
What should you be palpating for in a spinal examination?
Feel for any areas of tenderness (lumbar or thoracic), increased warmth or swelling. Spinous processes, sacro-iliac joints and soft tissues (paravertebral muscles spasm tenderness) should be palpated separately.
What should be assessed in move for spinal examination?
Assess flexion, extension, lateral bending and rotation. Schober‘s test cam used to quantify forward flexion.
What is Schober’s test?
- Lumbar spine movement - distance 5cm below PSIS line and 10cm above PSIS after patient bends over to touch toes, keeping their knees straight
- A difference of <5cm (<20cm) is abnormal
- Reduced lumbar flexion is commonly found in patients with ankylosing spondylitis
What other tests can be done in a spinal exam?
- Superficial tenderness: light touch over a wide lumbar area or deeper tenderness in non-anatomical areas
- Stimulation: manoeuvres that should not be painful when performed, such as axial loading of the head or passively rotating the shoulders or pelvis
- Distraction: performing a proactive test in the usual manner and rechecking when patient is distracted
- Regionalisation: presence of findings that diverge from accepted neuroanatomy
- Overreaction: e.g. collapsing, inappropriate facial expressions, excessive verbalisation
What is the 1st line non-invasive management for low back pain?
- Warn about red flags
- Return to normal activities and avoid bed rest
- Avoid precipitants
- Physiotherapy and advises to mobilise
What other examinations can be done alongside a spinal exam?
- DRE - to check anal tone and peri-anal sensation (check for bladder/bowel issues)
- Straight leg test - tests sciatic nerve L5/S1
- Femoral stretch test - L3/4
What is spinal stenosis?
- Usually gradual onset
- Unilateral or bilateral leg (with/without back pain), numbness, weakness, worse on walking, resolves when sitting down
- Pain may be aching/crawling
- Relieved on sitting down, leaning forwards, crouching down
- Clinical exam often normal - requires MRI for diagnosis
Describe ankylosing spondylitis
- Typically a young man who presents with lower back pain and stiffness
- Stiffness is usually worse in the morning and improves with activity, can be worse at night and helps when getting up
- Peripheral arthritis (more common in females)
Describe peripheral arterial disease (PAD)
- Pain on walking, relieved by rest
- Absent or weak foot pulses and other signs of limb ischaemia
- PMH may include smoking and other vascular diseases
What is the best imaging for non-specific lower back pain?
MRI - if result is likely to change management and for malignancy, infection, cauda equina suspicions etc
What is the analgesia recommended from back pain?
- NSAIDs are 1st line
- PPIs alongside for >45yrs
What are non-pharmacological treatments?
- Exercise programme
- Manual therapy (spinal manipulation, mobilisation or soft tissue techniques e.g. massage)
- Radiofrequency denervation
- Epidural injections of local anaesthesia and steroid for acute and severe sciatica
What treatments can be prescribed in pain clinics?
- Gabapentin
- Amitryptilline
- Topical analgesics: capsaicin + lidocaine
- TENS
What are the symptoms for L3 nerve root compression?
- Sensory loss over anterior thigh
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
What are the symptoms for L4 nerve root compression?
- Sensory loss anterior knee
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
What are the symptoms for L5 nerve root compression?
- Sensory loss dorsum of foot
- Weakness in foot and big toe dorsiflexion
- Reflexes intact
- Positive sciatic nerve stretch test (straight leg test)
What are the symptoms for S1 nerve root compression?
- Sensory loss posterolateral aspect of leg and lateral aspect of foot
- Weakness in plantarflexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
What is the management for prolapsed discs?
Analgesia, physiotherapy, exercise. If symptoms persist (4-6 weeks) then referral for MRI.
What are the symptoms of lower motor neuron lesions?
- Muscle weakness - proximal and distal
- Hypotonia
- Fasiculations present
- Hypo/areflexia
- Sensory loss peripherally
- Abnormal nerve conduction
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Rheumatology26
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Back Pain32
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Vasculitis25
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Orthopaedics21
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History Taking6
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Making a Diagnosis8
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Treatment16
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Medications9
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Trauma call20
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Childhood Fracture10
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Rheumatoid Arthritis27
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Osteoarthritis15
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Gout13
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Hip Pain in a Child13
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Systemic Lupus Erythematosus19
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Rotator Cuff Injury17
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Fibromyalgia12
