Back pain

Question 1

What are the 2 classes of back pain?

Answer 1

Non-inflammatory

Inflammatory with underlying pathology

Question 2

Define mechanical back pain?

Answer 2

Lower back pain that arises from damage to spinal joints, vertebrae, discs or soft tissue due to physical forces

Question 3

According to NICE, does mechanical back pain have an association with serious/potentially serious underlying causes?

Answer 3

No

Question 4

How can degenerative disc disease cause mechanical back pain?

Answer 4

Degenerative disc disease causes discogenic pain (pain that arises from damaged intervertebral disc), which is a type of mechanical back pain

Question 5

In which spinal region does disc herniation most commonly cause mechanical back pain?

Answer 5

Lumbar disc herniation

Question 6

What is spondylosis, and how can it lead to mechanical back pain?

Answer 6

Spondylosis is spinal OA, which causes degenerative changes such as facet joint pain and stiffness

Question 7

What percentage of all worldwide back pain cases are caused by mechanical back pain?

Answer 7

90% of all back pain cases

Question 8

Which world region has the highest prevalence of mechanical back pain?

Answer 8

Western Europe

Question 9

What percentage of Europeans have mechanical back pain?

Answer 9

42%

Question 10

What is the normal age range of onset for mechanical back pain?

Answer 10

20-55 years

Question 11

How does prevalence of mechanical back pain change with age?

Answer 11

Prevalence increases with age until 60s, then peaks around 70 years and declines

Question 12

How does mechanical back pain present at different times in the day?

Answer 12

Mechanical back pain worsens throughout day and is worst at night

Question 13

What 3 areas does pain radiate to when a patient has mechanical back pain?

Answer 13

Lumbosacral spine
Buttocks
Thighs

Question 14

Does a patient with mechanical back pain present with systemic symptoms?

Answer 14

No, patient is generally well

Question 15

When investigating mechanical back pain, what 3 factors must be assessed and documented?

Answer 15

Possible nerve root irritation

Any neurological signs

Any symptoms, so that CES can be excluded

Question 16

What percentage of patients with mechanical back pain recover within a week?

Answer 16

50%

Question 17

What percentage of patients with mechanical back pain recover within 6 weeks?

Answer 17

90%

Question 18

What percentage of patients have recurrent mechanical back pain within a year?

Answer 18

60%

Question 19

How long do recurrent attacks of mechanical back pain take to settle, and does their prevalence change with age?

Answer 19

Recurrent attacks settle within 3-5 years

Attacks peak in middle age and become less frequent as age increases

Question 20

Define sciatica?

Answer 20

A type of radiculopathy of a sciatic nerve root, causing pain that originates along sciatic nerve

Question 21

How is sciatica described instead of a type of radiculopathy, and why is this description of sciatica more commonly used?

Answer 21

More commonly described as leg pain secondary to lumbosacral nerve root pathology, because this more clearly understood by patients

Question 22

83% sciatica cases arise from disc herniation of which 2 nerve roots?

Answer 22

Either L5 (51%) or S1 (22%)

Question 23

What percentage of sciatica cases arise due to polyradiculopathy, and which 2 nerve roots are both affected?

Answer 23

10% cases

Both L5 and S1

Question 24

Which 2 nerve roots are commonly affected in elderly patients that cause sciatica, and what percentage of all sciatica cases does this occur in?

Answer 24

17% cases affect L3 or L4, which typically occur in elderly patients

Question 25

Can sciatica be a symptom of spinal stenosis?

Answer 25

Yes

Question 26

What condition is sciatic commonly mistaken for?

Answer 26

Neurogenic claudication: Compression of nerve root in lumbar sacral spine that causes intermittent leg pain, fatigue, numbness

Question 27

What percentage of the general population get sciatica in their lifetime (lifetime incidence)?

Answer 27

13-40%

Question 28

What is the rate of annual incidence (new cases in a year) of a sciatica episode?

Answer 28

1-5%

Question 29

What is the normal age range of onset of sciatica?

Answer 29

20-50, prevalence increases in age and reaches peak in 50s Declines after 50s

Question 30

In sciatica, where does the pain radiate to, and is it bilateral or unilateral?

Answer 30

Unilateral leg pain that radiates from lower back/buttocks and spreading down leg below knee

Question 31

How does sciatic pain affect the muscles in the back?

Answer 31

Pain radiating from lower back to below knee causes lumbago (limited function of lumbar back muscles)

Question 32

Give 2 examples of sensations in the leg caused by sciatica?

Answer 32

Numbness Paraesthesia

Question 33

How do you perform the sciatic stretch/straight leg raising (SLR) test, and what is the positive result?

Answer 33

Flex hip and raise straight leg, if patient feels pain below knee on posterior calf between 30 and 70 degrees hip flexion, the test is positive and suggests sciatica

Question 34

How do you perform the femoral nerve stretch test, and what is the positive result?

Answer 34

Flex knee while patient is lying prone (face-down), if flexion causes anterior thigh pain test is positive and suggests nerve root impingement

Question 35

What 2 special tests are performed to test for sciatica, and what are the indications of their positive results?

Answer 35

Femoral nerve stretch test positive result suggests nerve root impingement Sciatic stretch/straight leg raising (SLR) test positive result suggests sciatica

Question 36

How long does it take to recover from sciatica?

Answer 36

Many cases of sciatica recover within 4-6 weeks without treatment Severe cases can take weeks-months to recover

Question 37

How can enthesitis due to AxSpA lead to back pain?

Answer 37

Enthesitis in spinal ligaments and tendons causes ossification in response, which produces bony spurs which can compress nerves and nerve roots

Question 38

When a patient has spondylosis, which vertebral structure has degenerated due to OA most commonly?

Answer 38

Facet joint OA

Question 39

How does pain present throughout the day in spondylosis, and what exacerbates the pain?

Answer 39

Pain is worst at night and is exacerbated by exercise/weight-bearing as this stresses joint

Question 40

Does spinal stenosis commonly occur in young or elderly patients?

Answer 40

Elderly patients

Question 41

What 3 actions make leg pain caused by spinal stenosis worse?

Answer 41

Exertion Exercise Standing

Question 42

What 2 actions relieve leg pain caused by spinal stenosis?

Answer 42

Resting for over 10 min Bending forwards

Question 43

Who do vertebral fractures most commonly affect, and describe the symptoms?

Answer 43

Commonly occurs in teenagers who play sports asymptomatic but can be associated with low back pain

Question 44

What is pars interarticularis?

Answer 44

Bony bridge between superior articular facet and inferior articular facet of a vertebral arch

Question 45

Define spondylolysis?

Answer 45

Compression/stress fracture of pars interarticularis, but vertebral bodies aren't displaced

Question 46

Define spondylolisthesis?

Answer 46

Compression/stress fracture of pars interarticularis which causes vertebral body to be displaced anteriorly to one directly beneath

Question 47

What radiological imaging is done to investigate a vertebral fracture?

Answer 47

Oblique plain radiograph If patient has neurological symptoms then MRI is ordered

Question 48

What is the primary method of treating vertebral fractures?

Answer 48

Conservative treatment Spinal fusion is rare

Question 49

How does vertebral osteomyelitis and discitis spread?

Answer 49

Haematogenous spread

Question 50

Give 2 investigations to identify the original infection causing vertebral osteomyelitis and discitis?

Answer 50

Blood cultures Check for inflammatory markers

Question 51

Describe the onset and 3 symptoms of back pain caused by vertebral osteomyelitis and discitis?

Answer 51

Insidious onset Spinal tenderness is common 15% have nerve root compression symptoms and signs Less than 50% cases have fever

Question 52

If a patient is suspected to have vertebral osteomyelitis and discitis, what region of their spine is imaged using MRI?

Answer 52

Whole spine MRI Up to 10% cases affect multiple segmental levels

Question 53

According to NICE, when should patients with non-inflammatory back pain be referred for further investigation?

Answer 53

High prognosis of poor outcome

Question 54

According to NICE, when should patients with non-inflammatory back pain be referred for imaging?

Answer 54

Only if result is likely to change management

Question 55

Give 2 activities that patients are encouraged and facilitated to continue in order to manage pain?

Answer 55

Normal hobbies and activities Work

Question 56

Give 2 examples of manual therapy for non-inflammatory back pain that are approved by NICE?

Answer 56

Massage Spinal manipulation

Question 57

What example of manual therapy for non-inflammatory back pain is not approved by NICE?

Answer 57

Accupuncture

Question 58

Give an example of psychological therapy for non-inflammatory back pain that is approved by NICE?

Answer 58

CBT

Question 59

Give 2 reasons why group exercise programmes and any physical activity is recommended by NICE for non-inflammatory back pain?

Answer 59

Relieves venous congestion and oedema Muscle afferent activity can interfere with pain processing

Question 60

Which 2 pharmacological therapies are recommended by NICE for management of non-inflammatory back pain?

Answer 60

Oral NSAIDs Weak opioids with/without paracetamol

Question 61

Give 3 examples of clothing that a patient with non-inflammatory back pain shouldn't wear, according to NICE?

Answer 61

Foot orthotics Belts Corsets

Question 62

Does NICE recommend to have nerve stimulation procedures to manage non-inflammatory back pain?

Answer 62

No, patient should not have them

Question 63

What 3 procedures are recommended by NICE to treat non-inflammatory back pain?

Answer 63

Nerve root/epidural injection Spinal fusion Radiofrequency denervation

Question 64

How are patients managed if they don't recover from non-inflammatory back pain after 6 weeks, according to NICE?

Answer 64

Biological, psychological, social assessments to check for red flag symptoms Eg. family relationships, depression and work situation

Question 65

Give 10 red flags for potential inflammatory back pain?

Answer 65

malignancy corticosteroid use systemic unwellness (especially weight loss) thoracic pain IV drug use HIV positive patient is not within 20-55 age range violent trauma widespread neurology severe restriction of lumbar flexion so patient can’t move back