back pain Flashcards
back pain red flags
night pain
systemically unwell
progressive motor or sensory deficit
age <20 or >50yrs
history of malignancy
history of trauma
suspected infection presentation
fever/chills
immunosuppression
IV drug use
dental status
foreign travel
suspected fracture presentation
old lady
osteoporotic
significant trauma
chronic steroid use
suspected cauda equina presentation
bilateral sciatica
urinary incontinence
decreased anal tone
loss of perianal sensation - saddle anaethesia
suspected AAA presentation
age >60
abdominal pulsating mass
pain at rest
suspected anylosing spodylitis presentation
young man with lower back pain + stiffness
stiffness worse in morning + improves with activity
suspected peripheral arterial disease presentation
pain on walking, relieved by rest
absent or weak foot pulses + other signs of limb ischaemia
smoker, other vascular diseases
suspected spinal stenosis presentation
gradual onset
uni/bilateral leg pain, numbness, weakness which is worse on walking
resolves when sits down
aching/craling pain
relieved by leaning forwards, crouching, sitting down
requires MRI to confirm diagnosis
which test rules out sciatica
straight leg raise
sciatic nerve goes through femoral
back pain investigations
most dont need, 70-90% resolve within a month
xray - only for young men (SIjoint to exclude ankylosing) or elderly (exclude collapse, fractures malignancy)
MRI - neurological signs
bone scan - osteomyeltis, pagets, metastases
when to investigate
no improvement after 4-6wks
red flags
patient presenting with signs of cauda equina
urgent MRI of lumbar spine
examine for sensitive dermatomes
commonest = L4/L5
-> effects lateral thigh, lateral calf + anterior calf
WHO pain ladder
Nonopiod +/- adjuvant therapy
a. Paracetamol + NSAIDs
Weak opiod (+/- nonop or adj)
a. Codeine + tramadol
Strong opoids (+/- nonop or adj)
a. Morphine, oxycodone, fentanyl + buprenorphine
adjuvant analgesics
= painkillers whose primary indication is for something other than pain
Anticonvulsants – gabapentin, pregabalin
Antidepressants – amitriptyline (tricyclic), duloxetine(SNRI)
o 1st line drug for neuropathic pain = amitriptyline (tricyclic antidepressant)
-> SE
* Constipation
* Dizziness
* Dry mouth
