BACK PAIN

Question 1

What is acute vs chronic low back pain?

Answer 1

Acute low back pain as lasting less than 3 months
Chronic low back pain as lasting 3 months or more

Question 2

Epidemiology of low back pain?

Answer 2

Up to 60% of the adult population will have low back pain at some point in their lifetime
5-7% of adults over 45 have chronic low back pain

Question 3

Prognosis of non-specific low back pain?

Answer 3

Self-limiting condition and usually resolved within a few weeks
People often have acute on chronic symptoms and episodes of recurrence

Question 4

Possible complications of non-specific low back pain?

Answer 4

Impact on ADLs and function
Depression and anxiety
Time of work, reduced productivity and loss of employment
Increased risk of falls
Immobility and physical reconditioning - esp in elderly
Chronic pain

Question 5

Red flags for cauda equina syndrome?

Answer 5

Sudden-onset bilateral Radicular leg pain or unilateral Radicular pain progressing to bilateral pain
Recent onset urinary retention or overflow urinary in continence
Faecal incontinence or recent onset loss of sensation of rectal fullness
Recent onset ED or sexual dysfunction
Perianal or perineal sensory loss
Gait disturbance

Question 6

Red flags for spinal fracture?

Answer 6

Sudden onset severe central spinal pain relieved by lying down
History of major trauma
Structural deformity of the spine
Point tenderness over a vertebral body

Question 7

Red flags for cancer causing back pain?

Answer 7

Age over 50
Gradual onset of symptoms or progressive pain
Severe unremitting lumbar pain, thoracic back pain, night spinal pain preventing sleep or spinal pain aggravated by straining e.g. coughing
Localised spinal tenderness
Mechanical pain
No symptomatic improvement after 4-6 weeks of conservative Tx
Unexplained weight loss
Claudication
Past Hx of cancer

Question 8

Management of low back pain?

Answer 8

Provided you have risk stratified and they have no red flags…

Offer reassurance and self-management strategies e.g. keep active, local heat
NSAIDs if needed (with PPI if over 45)
Offer advice on exercise programmes, PT for manual therapy or psychological support
Advice requesting an occupational health assessment

Advice person to arrange review if symptoms persist or worsen after 4 weeks

Question 9

Investigations for non-specific lower back pain?

Answer 9

MRI only if result is likely to change management e.g. if malignancy is suspected!!

Question 10

What is sciatica?

Answer 10

Radiating leg pain caused by inflammation or compression of the Lumbosacral nerve roots forming the sciatic nerve (L4-S1)

Aka Radicular pain, lumbar radiculopathy, Lumbosacral Radicular syndrome

Question 11

Prevalence of sciatica?

Answer 11

Lifetime prevalence is 13-40%
5-10% of people with non-specific low back pain also have sciatica
Incidence is related to age, peaking in the 5th decade before declining

Question 12

Causes of sciatica?

Answer 12

Herniated intervertebral disc - 90%
Spondylolisthesis
Spinal stenosis
Infection (rare)
Cancer (rare)

Question 13

Risk factors for sciatica?

Answer 13

Smoking
Obesity
Occupation - whole body vibration or strenuous physical activity e.g. frequent heavy lifting
Older age
Genetic influences

Question 14

Prognosis of sciatica?

Answer 14

50% recover spontaneously within 6 weeks
Recurrence is common

Question 15

Symptoms of sciatica?

Answer 15

Unilateral sharp leg pain radiating below the knee to the foot or toes
Low back pain (usually not as bad as the leg pain)
Pain is often worse when sitting and can be exacerbated by coughing/sneezing/straining
Numbness and paraesthesia in the dermatome - mostly back of thigh/calf and foot
Muscle weakness may cause diffiuclty lifting the foot, pointing toes etc (depends on specific nerve root)
Loss of ankle jerk reflex
A positive result in a straight leg raise test

Question 16

What questionnaire can be used in primary care for back pain-related disability?

Answer 16

STarT back screening tool

Question 17

Examination tests for sciatica?

Answer 17

Straight leg raise

Question 18

Features of L3 nerve root compression?

Answer 18

Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test

Question 19

Features of L4 nerve root compression?

Answer 19

Sensory loss anterior aspect of knee and medial malleolus
Pain from outer hip, over anterior knee and round to medial malleolus in the line
Weak knee extension and hip adduction
Difficulty with squat and rise
Reduced knee reflex
Positive femoral stretch test

Question 20

Features of L5 nerve root compression?

Answer 20

Sensory loss dorsum of foot and lateral aspect of lower leg
Pain from midline back, around lateral gluteus and down lateral side of leg in a line
Weakness in foot and big toe dorsiflexion
Difficulty heel walking
Reflexes intact
Positive sciatic nerve stretch test

Question 21

Features of S1 nerve root compression?

Answer 21

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Pain from back down back of leg
Weakness in plantar flexion of foot
Difficulty walking on toes
Reduced ankle reflex
Positive sciatic nerve stretch test

Question 22

Management of sciatica?

Answer 22

Self management advice e.g. stay active
Analgesia - NSAIDs +/- PPI
Offer referral to group exercise, PT and psychological therapies
Promote and facilitate return to work or normal ADLs

Question 23

What is non-specific back pain?

Answer 23

Accounts for 85% of causes of acute back pain

When the back pain mostly involves the lumbar region, its derived from soft tissues/joints, not because of a disease or injury and is self-limiting

Question 24

What is a yellow flag?

Answer 24

The potential psychosocial pathologies that may prolong recovery and influence the outcome - i.e. highlights pt risk of chronicity

Question 25

Examples of yellow flags for back pain?

Answer 25

Attitudes towards the current problem - does pt feel self management will help them return to normal activities? Beliefs - pt believing they have something serious causing their bad pain or believing activity is harmful Compensation - is pt awaiting payment for an injury at work (ongoing litigation) Diagnosis - inappropriate communication leading to pt misunderstanding diagnosis Emotions - pts with concurrent depression are at higher risk of developing chronic pain Families - over bearing or under supportive Work - low support or dissatisfaction

Question 26

Causes of all back pain?

Answer 26

Muscle/ligament sprain Facet joint dysfunction Sacroiliac joint dysfunction Herniated disc Spondylolisthesis Scoliosis Degenerative changes Torticollis Whiplash Cervical spondylosis Spinal fracture Cauda equina Spinal stenosis Ankylsing spondylitis Spinal infections Pneumonia Ruptured AAA Kidney stones Pyelonephritis Pancreatitis PID Endometriosis

Question 27

Nerve roots of the sciatic nerve?

Answer 27

L4-S3

Question 28

Anatomical course of the sciatic nerve?

Answer 28

Derived from the Lumbosacral plexus Leaves the pelvis and enters gluteal region via greater sciatic foramen Emerges inferiroly to the piriformis muscle and descends in an inferolateral direction Enters posterior thigh by passing deep to the long head of the biceps femoris Within the posterior thigh it gives rise to the branches of the hamstring muscles and adductor Magnus When the sciatic nerve reaches the apex of the popliteal fossa it terminates by bifurcating into the tibial ans common fibular nerves

Question 29

Motor functions of sciatic nerve?

Answer 29

Posterior compartment of the thigh Hamstring portion of adductor Magnus And indirectly… Tibial nerve - posterior calf muscles and some intrinsic foot muscles Common fibular nerve - muscles of anterior leg, lateral leg and remaining intrinsic foot muscles

Question 30

Sensory functions of the sciatic nerve?

Answer 30

The sciatic nerve does not have any direct cutaneous functions. It does provide indirect sensory innervation via its terminal branches: Tibial nerve – supplies the skin of the posterolateral leg, lateral foot (sural) and the sole of the foot (medial calcaneal) Common fibular nerve – supplies the skin of the lateral leg (deep fibular and sural) and the dorsum of the foot (superficial fibular)

Question 31

What is piriformis syndrome?

Answer 31

Piriformis syndrome refers to compression of the sciatic nerve by the piriformis muscle. It is also known as deep gluteal syndrome. Caused by trauma, overuse injuries, contusion to gluteal area, hypertrophy of muscle e.g. in athletes, anatomical anomaly, tumours, vascular anomalies. Clinical features include middle-upper part of buttocks pain that radiates al down the leg, numbness, pin point tenderness on buttocks and muscle weakness. The pain can occasionally be exacerbated by internal rotation of the lower limb at the hip.

Question 32

Investigations for acute back pain?

Answer 32

FBC ESR and CRP Urinalysis PSA Protein electrophoresis CT or MRI if presence of red flags and imaging likely to alter management

Question 33

Which spinal roots form the lumbar plexus?

Answer 33

L1, L2, L3, L4

Question 34

What are the major branches of the lumbar plexus?

Answer 34

Iliohypogastric nerve Ilioinguinal nerve Genitofemoral nerve Lateral cutaneous nerve Femoral nerve Obturator nerve (I I Get Leftovers On Fridays)

Question 35

Roots of iliohypogastric nerve?

Answer 35

L1

Question 36

Function of iliohypogastric nerve?

Answer 36

Motor - internal oblique and transversus abdominis Sensory - posterolateral gluteal skin in pubic region

Question 37

Roots of ilioinguinal nerve?

Answer 37

L1

Question 38

Function of the ilioinguinal nerve?

Answer 38

Motor - internal oblique and transversus abdominis Sensory - skin on superior antero-medial thigh, root of penis and anterior scrotum, skin over mons pubis and labia majora

Question 39

Roots of genitofemoral nerve?

Answer 39

L1 and L2

Question 40

Functions of genitofemoral nerve?

Answer 40

motor - cremasteric muscle Sensory - skin of anterior scrotum, over mons pubis and labia majora

Question 41

Functions of lateral cutaneous nerve of the thigh?

Answer 41

Motor - none Sensory - anterior and lateral thigh down to the level of the knee

Question 42

Roots of the lateral cutaneous nerve of the thigh?

Answer 42

L2, L3

Question 43

Roots of obturatory nerve?

Answer 43

L2, L3, L4

Question 44

Functions of the obturator nerve?

Answer 44

Motor - muscles of medial thigh Sensory - skin over medial thigh

Question 45

Roots of femoral nerve?

Answer 45

L2, L3, L4

Question 46

Functions of the femoral nerve?

Answer 46

Motor - anterior thigh muscles Sensory - skin on anterior thigh and medial leg

Question 47

What roots form the sacral plexus?

Answer 47

S1, S2, S3, S4

Question 48

Branches of the sacral plexus?

Answer 48

Superior gluteal nerve Inferior gluteal nerve Sciatic nerve Posterior femoral nerve Pudendal nerve (Some Irish Sailors Pester Polly)

Question 49

Roots of superior gluteal nerve?

Answer 49

L4, L5, S1

Question 50

Functions of superior gluteal nerve?

Answer 50

Motor - gluteus minmus, gluteus medius and tensor fascia lata Sensory - none

Question 51

Roots of inferior gluteal nerve?

Answer 51

L5, S1, S2

Question 52

Functions of inferior gluteal nerve?

Answer 52

Motor - gluteus maximus Sensory - none

Question 53

Roots of sciatic nerve?

Answer 53

L4, L5, S1, S2, S3

Question 54

Roots of posterior femoral cutenaour nerve?

Answer 54

S1, S2, S3

Question 55

Function of posterior femoral cutaneous nerve?

Answer 55

Motor - none Sensory - skin on posterior surface of thigh and leg + skin of perineum

Question 56

Roots of pudendal nerve?

Answer 56

S2, S3, S4 (“S2, 3, 4 keeps the poo off the floor)

Question 57

Functions of pudendal nerve?

Answer 57

Motor - skeletal muscles in perineum, external urethral sphincter, external anal sphincter and levator ani Sensory - penis, clitoris and most skin of perineum

Question 58

What is spinal stensois?

Answer 58

A narrowing of part of the spinal canal resulting in compression of the spinal cord or nerve roots Most commonly affects the lumbar spine

Question 59

Who is spinal stenosis most common in?

Answer 59

Pt older than 60 relating to degenerative changes in the spine

Question 60

Types of spinal stenosis?

Answer 60

Central stenosis – narrowing of the central spinal canal Lateral stenosis – narrowing of the nerve root canals - compresses nerve roots Foramina stenosis – narrowing of the intervertebral foramina - compresses nerve roots

Question 61

Causes of spinal stenosis?

Answer 61

Congenital Degenerative changes - most common! Herniated discs Thickening of ligamenta flava or posterior longitudinal ligament Spinal fractures Spondylolisthesis Tumours

Question 62

Ligaments of the lumbar spine?

Answer 62

Anterior and posterior longitudinal ligaments run the length of the vertebral column and cover the vertebral bodies and intervertebral discs Ligamentum flavum connects laminae of adjacent vertebrae Interspinous ligament connects spinous processes of adjacent vertebrae Supraspinous ligament connects tips of adjacent spinous processes

Question 63

What is spondylolisthesis?

Answer 63

Anterior displacement of a vertebra out of line with the one below Happens with age and due to stress fractures

Question 64

Presentation of spinal stensois?

Answer 64

Gradual onset of Intermittent neurogenic claudication - lower back pain, buttock and leg pain with leg weakness Bending forwards improves symptoms as it expands the spinal canal Neuropathic pain - if severe compression there may be features of cauda equina syndrome or if more mild it may cause symptoms of sciatica

Question 65

Investigations for spinal stensois?

Answer 65

MRI Exclude PAD e.g. ABPI and CT angiogram

Question 66

Management of spinal stenosis?

Answer 66

Conservative - exercise, weight loss, analgesia, PT Laminectomy

Question 67

What are spondyloarthritis?

Answer 67

A term describing a group of clinically heterogenous inflammatory rheumatologic conditions May be axial (ankylosing spondylitis) or peripheral (psoriatic arthritis or reactive arthritis)

Question 68

How does ankylosing spondyltis present?

Answer 68

Young man with lower back pain and stiffness of insidious onset but for >3 months Stiffness if worse in the morning and improves with exercise Pain at night Reduced forward flexion and lateral flexion

Question 69

Which cancers most commonly metastasises to the spine?

Answer 69

Breast Lung Prostate Renal GI Thyroid

Question 70

Symptoms suggestive of spinal metastasis?

Answer 70

Unrelenting lumbar back pain that is progressive Any thoracic or cervical back pain Worse with sneezing, coughing or straining, standing, sitting or moving Nocturnal Associated with localised tenderness Past or current Ca diagnosis or suspected Ca diagnosis

Question 71

What are the 3 types of spinal tumours?

Answer 71

Extradural - within the vertebrae (most common and usually mets) Intramedullary - within the spinal cord Extramedullary - arise from a range of tissues (e.g. meningioma or schwannoma) within the space between the dura and the spinal cord

Question 72

What is the main complications of metastatic spinal tumours?

Answer 72

Metastatic spinal cord compression

Question 73

What are spinal haematomas and what are the different types?

Answer 73

Colectins of blood within the spinal canal which can compress the spinal cord and nerves Epidural, subdural, subarachnoid and Intramedullary (i.e. within the spinal cord itself)

Question 74

Types of spinal infections?

Answer 74

Vertebral osteomyelitis Discitis Spinal epidural abscess Meningitis Rare - spinal subdural emphysema and spinal cord abscess

Question 75

What is discitis?

Answer 75

An infection in the intervertebral disc space

Question 76

Presentation of discitis?

Answer 76

Back pain Fever, rigors, sepsis Neurological symptoms e.g. changing lower limb neurology

Question 77

Causes of discitis?

Answer 77

Bacterial - most commonly its caused by staph aureus Viral TB Aseptic Usually from haematological spread from UTI or TRI or post-op complication from staph aeurs

Question 78

Diagnosis of discitis?

Answer 78

MRI CT-guided biopsy may be required to guide antimicrobial treatment

Question 79

MRI findings in discitis?

Answer 79

Hyper intensity of the disc and inflammation surrounding it

Question 80

Treatment of discitis?

Answer 80

6-8 weeks of IV antibiotics

Question 81

What must all pt with discitis be assessed for?

Answer 81

Endocarditis - this is because discitis is usually due to haematogenous seeding so the seeding may have also occurred elsewhere

Question 82

Complications of discitis?

Answer 82

Sepsis Epidural abscess

Question 83

What is a spinal epidural abscess?

Answer 83

A collection of pus superficial to the dura mater covering the spinal cord It’s an emergency!!

Question 84

Outline the pathophysiology of spinal epidural abscess?

Answer 84

Bacteria enter the spinal epidural space by contiguous spread from adjacent structures e.g. discitis, haematogenous spread from concomitant infections e.g. IVDU, or direct infection e.g. spinal surgery More likely in immunosuppression

Question 85

Most common causative micro-orgasms of spinal epidural abscess?

Answer 85

Staph aureus

Question 86

Presentation of spinal epidural abscess?

Answer 86

fever back pain focal neurological deficits according to the segment of the cord affected.

Question 87

Investigations for spinal epidural abscess?

Answer 87

Bloods - CRP, HIV, hep B, Hep C, coag, group & save Blood cultures CXR and urinanalaysis/culture MRI whole spine

Question 88

Treatment of spinal epidural abscess?

Answer 88

All patients will require a long-term course of antibiotics which is at first broad spectrum but maybe later refined based on culture results. Patients with large or compressive abscesses, patients with significant or progressive neurological deficits or those who are not responding to antibiotics alone are considered for surgical evacuation of the abscess.

Question 89

Presentation of osteoporotic vertebral fractures?

Answer 89

Asymptomatic Acute back pain Breathing diffiuclties GI problems due to compression of abdominal organs Loss of height Kyphosis Localised tenderness on palpation of spinous processes

Question 90

What is scoliosis?

Answer 90

Curvature of the spine in the coronal plane Can be postural which means it typically disappears on manoeuvres such as bending forward

Question 91

What is spondylolysis?

Answer 91

This is a congenital weakness of stress fracture of the pars interarticularis of the neural arch of a particular vertebral body, usually L4/L5 Most common in children

Question 92

What is cervical spondylosis? Symptoms?

Answer 92

Degenerative disease of the neck Very common in people over 40 Causes neck & shoulder pain or stiffness that comes and goes. Often causes headaches that start at the back of the neck

Question 93

Femoral neuropathy presentation?

Answer 93

Groin pain Sensory disturbances above the knee Difficulty with knee extension and hip flexion Loss of muscle bulk of quadriceps Loss of patella jerk reflex

Question 94

Neurological level of reflexes?

Answer 94

Bicep C5 Supination C6 Tricep C7 Knee L3/L4 Ankle S1 Jaw - pons

Question 95

What is isthmic spondylolisthesis?

Answer 95

Subluxation of 1 vertebral body anterior to the adjacent inferior vertebral body caused by a defect in the pars interarticularis Affects L5/S1 and cause foraminal stenosis

Question 96

Who is isthmic spondylolisthesis most common in?

Answer 96

Those who do sports that involve repetitive hyperextension e.g. gymnasts, weight lifters

Question 97

Presentation of isthmic spondylolisthesis?

Answer 97

Axial back pain L5 radiculopathy Neurogenic claudication caused by spinal stenosis - buttock and leg pain worse with walking

Question 98

Most commonly affected disc for disc prolapse?

Answer 98

L5/S1

Question 99

Structure of the intervertebral discs?

Answer 99

Concentric collagen out fibres (annulus fibrosus) surround a central nucleus of degenerated collagen (nucleus pulposus)

Question 100

Why do we lose vertical height as we age?

Answer 100

The intervertebral discs hold a lot of water and as we age the disc dehydrates and we lose height

Question 101

Pathophysiology of disc herniation?

Answer 101

Intervertebral discs dehydrate as we age and this gradually weakens them and makes them prone to prolapse. This often occurs as a result of strenuous physical activity involving the lumbar spine

Question 102

Types of disc herniation?

Answer 102

Posterolateral - compresses next lower nerves - most common Central (posterior) - may compress the spinal cord or lead to cauda equina syndrome Lateral - nerve root compression

Question 103

Stages of disc herniation?

Answer 103

Bulging - extension of the disc margin beyond the margins of the adjacent vertebral endplates Protrusion - posterior longitudinal ligament remains intact but nucleus pulposus impinges annulus fibrosus Extrusion - nuclear material emerges through annular fibres but posterior longitudinal ligament remains intact Sequestration - the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space

Question 104

Presentation of disc prolapse?

Answer 104

Back pain Buttock or leg pain Altered sensation Motor weakness Altered reflexes

Question 105

Imaging modality of choice for disc herniation?

Answer 105

MRI

Question 106

Management of disc herniation?

Answer 106

90% will resolve spontaneously Activity modification, analgesia, PT In severe cases then local steroids injections can be given If it lasts >3 months, not responsive to analgesia, worsening neurological Sx etc - operation (microdiscectomy)