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Flashcards in Back pain Deck (16):

Differential diagnosis for back pain: mechanical, systemic, referred

1) Mechanical
Lumbar muscular strain/sprain
Herniated nucleus pulposus (HNP)
Spinal stenosis
Compression fracture
Degenerative disc disease or facet arthropathy
Spondylolysis and/or spondylolisthesis

2) Systemic
Vertebral discitis/osteomyelitis
Inflammatory spondyloarthropathy
Connective tissue disease

3) Referred
Aortic abdominal aneurysm
Renal colic
Peptic ulcer disease


Red flag conditions

Herniated nucleus pulposus (HNP)
Vertebral discitis/osteomyelitis/epidural abscess
Aortic abdominal aneurysm
Cauda equina


Red flag features for sinister cause

Aged 55 years
Acute onset in elderly
Worse on being supine
Fever, night sweats, weight loss
History of malignancy
Abdominal mass
Thoracic back pain
Morning stiffness
Bilateral/alternating leg pain
Neurological disturbance
Current/recent infection
Leg claudication


Risk factors for chronicity

Have you had time off work in the past with back pain?
What do you understand is the cause of your back pain?
What are you expecting will help?
How are your employer, coworkers, family responding to your back pain?
What are you doing to cope with back pain?
Do you think that you will return to work? When?


Yellow flags

Belief back pain in harmful/
Fear-avoidance/reduced activity
Tendency to low mood and withdrawal
from social interaction
Expectation of passive interventions
rather than a beleif that active
participation will help



Range of motion
Localised tenderness
A positive straight-leg raise or contralateral straight-leg raise
Neurological examination
Rectal tone


Investigations- blood

Not usually required
If suggestions of infection, malignancy: FBC, ESR, C-reactive protein (CRP), and blood cultures
Urinalysis if suspect pyelonephritis


Lumbar Xray

Lumbar X-ray rarely helpful-->
unless diagnsoisng AS,
will show OA changes,
disc narrowing-->
not recommended in acute/without
red flags
Consider after 6-8 weeks
?PSA-->prostatic Ca
ALP+-->MM, osteomalacia,
pagets, metastasis


Imaging if red flags

If red flags-->MRI,
CT if contrindicated(pacemaker,
metal clips)
MRI: 64% of normal (asymptomatic)
people have abnormalities in MRI


Management of mechanical

Advice to stay active,
education and reasurance
(90% recover in 6 weeks,
however recurrences are common
50% w/ intermittent),
avoid work disability

?Physical therapy

1g paracetamol 4-6 hourly,
max 4g
300mg ibuprofen 4X daily


How long to try NSAIDs, if not working

If pain persists consider
exacerbating factors.
Goal is not to be pain free,
but to be manageable

codeine 30 to 60 mg orally,
6-hourly as necessary


Lower limb neurological movements- spinal level

hip flexion
• L2, L3, L4
hip adduction
• L2, L3, L4
hip abduction
• L2, L3, L4
hip extension
• S1
knee extension
• L2, L3, L4
knee flexion
• L4, L5, S1, S2
foot dorsiflexion (walk on heels)
• L4, L5
foot plantarflexion (walk on toes)
• S1


Grading muscle strength

o grading of muscle strength
• 0 – no muscle contraction detected
• 1 – flicker or trace contraction
• 2 – active movement with gravity eliminated
• 3 – active movement against gravity
• 4 – active movement against gravity and some resistance
• 5 – active movement against full resistance without evident fatigue (normal)


Describe the slump test

Slump test
• Seat patient with legs hanging off bed
• Slump patient forward at thoracolumbar spine
• If this position does not cause pain, ask patient to flex neck, then extend one knee as much as possible
• If pain is felt, return neck to normal position; if the patient is still unable to extend knee due to pain, the test is POSITIVE
• If extending the knee does not cause pain, ask patient to actively dorsiflex ankle; if dorsiflexion causes pain, ask patient to slightly flex the knee while still dorsiflexing; if pain is reproduced, test is positive
• Perform bilaterally
• Positive test indicates likely lumbar disc herniation


What is radicular pain

Radicular pain, caused by nerve root compression from a disc protrusion (most common cause) or tumour or a narrowed intervertebral foramina, typically produces pain in the leg related to the dermatome and myotome innervated by that nerve root. Leg pain may occur alone without back pain and vary considerably in intensity.


Characteristics of radicular pain

• Any age, usually middle-aged
History of injury:
• Yes, lifting or twisting
• Can be spontaneous
Site and radiation:
• Unilateral low back, distal radiation along dermatome, tends to have a 'distal' emphasis
Type of pain:
• Deep aching or stabbing pain (episodic) develops soon after rising in morning
• Has a 'travelling' nature
• Activity, lifting, intercourse, sitting, bending, car travel, coughing, sneezing, straining
• Rest, lying, standing
• Distal paraesthesia ± numbness, stiffness
Diagnostic confirmation (for special reasons):
• CT scan, discogram, radiculogram, MRI or myelogram
The two nerve roots that account for most of these problems are L5 and S1. Most settle with time (6 to 12 weeks).