Back Pain profoma Flashcards
What are the causes of back pain?
Malignancy
Infections:
- Disciitis
- Vertebral osteomyelitis
Mechanical back pain:
- Osteoarthritis of the spine
- Prolapsed intervertebral disc
- Vertebral crush fracture
- Spinal stenosis/spondylolisthesis
What are the Red-flag symptoms of back pain?
Bowel or bladder dysfunction- loss of anal sphincter tone or urinary retention
Constant, progressive pain unrelieved by rest
Major trauma
Unexplained weight loss & nigh sweats
Thoracic back pain
Immunosuppression
UTI
History of cancer
IV Drug use
Prolonged use of corticosteroids
Osteoporosis
Global or progressive motor weakness in lower limbs.
Duration of lower back pain is over 6 weeks & not improving w/ conservative management.
Initial investigation for back pain
- Nerve root irritation tests - i.e. straight leg raises, femoral stretch test…
- Blood tests - useful if you suspect infection, cancer, metabolic or inflammatory disorders.
- MRI - useful for most spinal conditions that you are trying to rule out.
- Used to check nerves - X-ray- useful for compression fractures but can be used in malignancy or spinal stenosis too.
- Bone scintigraphy (isotope bone scan) - can help diagnose cancer.
- identifies areas of physical & chemical changes in bone. - CT for positioning of the bones
Management for back pain
- Simple low back pain:
- NSAIDs e.g. ibuprofen, naproxen
- Encourage normal activities & return to work.
- Loose weight & group exercise.
- Educate - explain it’s self-limiting & exercise helps.
- Safety net - “come back in 6 weeks if hasn’t improved”.
- Do not refer for imaging unless it will change care. - If the simple lower back pain isn’t getting better:
- Massage or spinal manipulation.
- Psychological therapy e.g. CBT
- weak opioids.
- Low dose anti-depressants may help sleep & mood.
- Epidural or facet joint injection - Red flag back pain:
- Cauda equina or infection - urgently to A&E & take MRI!
- Cancer - urgent MRI or x-ray & pain relief using WHO ladder.
- Inflammatory back pain - refer to rheumatologist.
Epidemiology of mechanical back pain
80% of population
Patients over 60 yr rarely present w/ mechanical back pain
- symptoms usually subside
- due to stiffening of a mobile spine.
Aetiology and pathophysiology of mechanical back pain
features of osteoarthritis:
- joint space destruction
- osteophyte formation.
Degenerative disc disease occurs w/ ageing & is related to decreased water content in nucleus pulposus. - Disc space narrows & the segment becomes more mobile.
- This abnormal movement, together w/ inability to distribute load, causes pain
Clinical presentation of mechanical back pain? Investigations? Management?
- Onset often sudden & precipitated by bending or lifting.
- Pain worse in the evening & on movement.
- Pain improves on rest.
- Pain in lumbosacral, buttock and thigh regions.
- Does not usually radiate to legs, if it does, then the pain doesn’t travel below the knee.
- Muscle spasms
- No systemic features
- No clear-cut nerve root distribution.
- Loss of lumbar lordosis
Investigation:
- x-ray may show- OA, minor disc narrowing or normal spine
- CRP, ESR, LFT etc all normal
Management:
- NSAID, rest, physio
- no surgery required
What is a prolapsed disc?
When part of the nucleus pulposus herniates through the annulus fibrosus (due to tear or rupture) & presses on spinal nerve root.
Also known as herniated disc
different to bulging- fluid bulging out slightly but not fully out
Aetiology and pathophysiology of prolapsed disc
herniation of disc material tends to occur posterolaterally where the annulus is thinner.
Central disc prolapse can occur & press on combined nerve roots, including those supplying bladder & bowel (cauda equina syndrome).
Prolapse can occur w/out spinal root involvement
- patient will have symptoms of back pain but not true sciatica.
Clinical presentation of prolapsed disc
Commonly occurs at L5-S1 or L4-L5
UNILATERAL sciatica
- Severe pain radiating down the leg as far as the toes.
- numbness + tingling + weakness of foot.
uncomfortable to sit or stand
- abnormal posture- stooping to affected side & standing w/ knee flexed to relieve pressure on dura
- Unable to stand on tip toes or heels due to weakness
Positive straight leg raise
Positive trendelengubrgs- L5 or L5 compressed
Loss of reflexes such as ankle jerk - common in L5 - S1 compression.
Cauda equina!- check for red flags!!!
Investigations
- take MRI - don’t take unless pain present for 4-6 weeks
- X-ray usually normal- don’t to exclude bony pathology e.g. spondylolisthesis
- Blood tests
Management
- NSAID, rest, physio
- Surgical diseconomy only required if cauda equina or pain more than 3 months
- Lumbar nerve root injection can provide diagnosis & treatment for nerve root compression.
- if pain > 3 months- surgery- will not treat but will improve leg symptoms
What is spondylolysis? What is spondylolithesis
Spondylolysis is a crack in the Pars Interarticularis (a small segment of bone that joins the facet joints in the spine).
Spondylolithesis is where the crack has allowed the whole vertebra to move forwards.
Related to sports injuries in teenagers
Clinical presentation of spondylolysis & spondylolithesis
Can be asymptomatic
low back pain.
Sciatica of spine possible if nerve root compressed
kyphosis possible
Radicular symptoms more common in adults
Central spinal tenderness.
Movement usually preserved, but classically hyperextension is painful.
Management
- X-ray to see if bones are out of place
- MRI if nerve root irritation is suspected.
-CT for lesions.
Conservative treatment - PT, NSAIDs, rest (short period) & corticosteroid injections.
- Spinal fusion in rare cases.
What is spinal stenosis?
A narrowing of spinal canal which can put pressure on your spinal cord e.g. by osteophytes, herniated discs, tumours, fractures.
Clinical presentation of spinal stenosis? Management?
- Can be bilateral leg pain that is brought on by walking
- Intermittent back pain, burning, heaviness, weakness or numbness radiating to thigh or calves
- Pain worse on prolonged standing/exercise & better on sitting or lying down.
- Better when leaning forwards so walking uphill is easier.
- Fatigue on walking & activities
- Typically seen in older patients
- Risk fcators include previous back surgery & manual labour
Management:
- Get an MRI
- Temporary reduction in physical activity
- NSAIDs and Paracetamol
- Corticosteroids if pain isn’t being controlled after 7 days (but this is controversial).
- Spinal fusion can be used for serious cases.
What is scoliosis?
A lateral curved spine w/ uneven shoulders & leaning to 1 side
