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Clinical lectures > Back pain > Flashcards

Back pain Flashcards

1
Q

What are the 2 classes of back pain?

A

Non-inflammatory

Inflammatory with underlying pathology

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2
Q

Define mechanical back pain?

A

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

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3
Q

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

A

No

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4
Q

How can degenerative disc disease cause mechanical back pain?

A

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

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5
Q

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

A

Lumbar disc herniation

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6
Q

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

A

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

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7
Q

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

A

90% of all back pain cases

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8
Q

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

A

Western Europe

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9
Q

What percentage of Europeans have mechanical back pain?

A

42%

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10
Q

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

A

20-55 years

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11
Q

How does prevalence of mechanical back pain change with age?

A

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

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12
Q

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

A

Mechanical back pain worsens throughout day and is worst at night

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13
Q

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

A

Lumbosacral spine
Buttocks
Thighs

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14
Q

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

A

No, patient is generally well

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15
Q

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

A

Possible nerve root irritation

Any neurological signs

Any symptoms, so that CES can be excluded

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16
Q

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

A

50%

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17
Q

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

A

90%

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18
Q

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

A

60%

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19
Q

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

A

Recurrent attacks settle within 3-5 years

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

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20
Q

Define sciatica?

A

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

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21
Q

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

A

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

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22
Q

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

A

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

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23
Q

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

A

10% cases

Both L5 and S1

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24
Q

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

A

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

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25
Q

Can sciatica be a symptom of spinal stenosis?

A

Yes

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26
Q

What condition is sciatic commonly mistaken for?

A

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

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27
Q

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

A

13-40%

28
Q

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

A

1-5%

29
Q

What is the normal age range of onset of sciatica?

A

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

Declines after 50s

30
Q

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

A

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

31
Q

How does sciatic pain affect the muscles in the back?

A

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

32
Q

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

A

Numbness

Paraesthesia

33
Q

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

A

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

34
Q

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

A

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

35
Q

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

A

Femoral nerve stretch test positive result suggests nerve root impingement

Sciatic stretch/straight leg raising (SLR) test positive result suggests sciatica

36
Q

How long does it take to recover from sciatica?

A

Many cases of sciatica recover within 4-6 weeks without treatment

Severe cases can take weeks-months to recover

37
Q

How can enthesitis due to AxSpA lead to back pain?

A

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

38
Q

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

A

Facet joint OA

39
Q

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

A

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

40
Q

Does spinal stenosis commonly occur in young or elderly patients?

A

Elderly patients

41
Q

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

A

Exertion
Exercise
Standing

42
Q

What 2 actions relieve leg pain caused by spinal stenosis?

A

Resting for over 10 min

Bending forwards

43
Q

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

A

Commonly occurs in teenagers who play sports

asymptomatic but can be associated with low back pain

44
Q

What is pars interarticularis?

A

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

45
Q

Define spondylolysis?

A

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

46
Q

Define spondylolisthesis?

A

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

47
Q

What radiological imaging is done to investigate a vertebral fracture?

A

Oblique plain radiograph

If patient has neurological symptoms then MRI is ordered

48
Q

What is the primary method of treating vertebral fractures?

A

Conservative treatment

Spinal fusion is rare

49
Q

How does vertebral osteomyelitis and discitis spread?

A

Haematogenous spread

50
Q

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

A

Blood cultures

Check for inflammatory markers

51
Q

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

A

Insidious onset

Spinal tenderness is common

15% have nerve root compression symptoms and signs

Less than 50% cases have fever

52
Q

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

A

Whole spine MRI

Up to 10% cases affect multiple segmental levels

53
Q

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

A

High prognosis of poor outcome

54
Q

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

A

Only if result is likely to change management

55
Q

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

A

Normal hobbies and activities

Work

56
Q

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

A

Massage

Spinal manipulation

57
Q

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

A

Accupuncture

58
Q

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

A

CBT

59
Q

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

A

Relieves venous congestion and oedema

Muscle afferent activity can interfere with pain processing

60
Q

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

A

Oral NSAIDs

Weak opioids with/without paracetamol

61
Q

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

A

Foot orthotics

Belts

Corsets

62
Q

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

A

No, patient should not have them

63
Q

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

A

Nerve root/epidural injection

Spinal fusion

Radiofrequency denervation

64
Q

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

A

Biological, psychological, social assessments to check for red flag symptoms

Eg. family relationships, depression and work situation

65
Q

Give 10 red flags for potential inflammatory back pain?

A

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

Clinical lectures (29 decks)

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