Back Pain & Sciatica

Question 1

List 3 general red flags in back pain

Answer 1

Failure to improve after 4-6 weeks conservative therapy,
Night pain/pain at rest
Progressive motor/sensory deficit

Question 2

List 5 cancer red flags of back pain

Answer 2

Age >50, 
Unintended weight loss,
Hx cancer,
Night pain 
Pain lying down

Question 3

List 6 red flags for infection in back pain

Answer 3

Fever/chills, 
Recent infection, 
Immunosuppression, 
IV drug use,
Dental status, 
Foreign travel

Question 4

List 4 red flags for fracture in back pain

Answer 4

Age >50,
osteoporosis,
Significant trauma,
Chronic steroid use

Question 5

List 5 red flags for Cauda Equina Syndrome in back pain

Answer 5

Bilateral sciatica, 
Urinary incontinence, 
Decreased anal tone, 
Loss of perianal sensation,
Leg weakness (not always)

Question 6

List 3 red flags for AAA in back pain

Answer 6

Age >60,
abdo pulsating mass,
Pain at rest

Question 7

What does the Straight leg raise test assess?

Answer 7

Hip is flexed until pain is noted which stretches hamstrings and sciatic nerve. Patients with herniated disc often experience back pain radiating to lower leg

Question 8

Weak leg flexion is problem with what nerve roots

Answer 8

L2,3

Question 9

Weak leg extension is problem with what nerve roots

Answer 9

L4,5

Question 10

Weak knee extension is problem with what nerve roots

Answer 10

L3,4

Question 11

Weak knee flexion is problem with what nerve roots

Answer 11

L5,S1

Question 12

Weak ankle dorsiflexion is problem with what nerve roots

Answer 12

L4,5

Question 13

Weak ankle plantar flexion is problem with what nerve roots

Answer 13

S1,2

Question 14

Weak ankle inversion is problem with what nerve roots

Answer 14

L4

Question 15

Weak ankle eversion is problem with what nerve roots

Answer 15

L5,S1

Question 16

MRC is used to grade muscle power. Outline meaning of Grade 0-5

Answer 16

0 - complete paralysis
1 - flicker of contraction possible
2 - movement possible if gravity eliminated
3 - movement against gravity but not resistance
4 - movement possible against some resistance
5 - power normal

Question 17

Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for L4 nerve root problem

Answer 17

Pain: felt along outside of leg and down front of knee and shine 
Numbness: felt on and above knee
Motor weakness: quads extension 
Screening exam: squat and rise
Reflexes: knee jerk diminished

Question 18

Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for L5 nerve root problem

Answer 18

Pain: bum and then down along outer edge of whole leg
Numbness: outer calf and side of leg
Motor weakness: dorsiflexion of great toe and foot
Screening exam: heel walking
Reflexes: none reliable

Question 19

Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for S1 nerve root problem

Answer 19

Pain: bum and then down along middle of the back of the whole leg
Numbness: back of calf and bottom of foot
Motor weakness: plantar flexion of great toe and foot
Screening exam: walking on toes
Reflexes: ankle jerk diminished

Question 20

Triceps reflexes tests what nerve roots?

Answer 20

C7,C8

Question 21

Biceps reflexes tests what nerve roots?

Answer 21

C5, C6

Question 22

Patellar reflexes tests what nerve roots?

Answer 22

L2, L3, L4

Question 23

Achilles reflexes tests what nerve roots

Answer 23

S1

Question 24

70-90% of LBP will resolve within a month. True/false?

Answer 24

True

Question 25

X-rays are not very useful for back pain as do not show soft tissue. What are two exceptions where x-rays should be used for back pain?

Answer 25

Young men: SI-joint to exclude ank spond | Elderly: to exclude vertebral collapse, fractures, malignancy

Question 26

What are EOS scans and what are they used for?

Answer 26

EOS are full spinal xrays with 10% of femur, useful for deformity and surgical planning

Question 27

What are CTs useful for and what are they not useful for?

Answer 27

Show bony pathology, foreign bodies, implants, spinal fusion planning and if MRI contra-indicated. Not very useful in acute LBP with no red flags

Question 28

Gold standard for lower back pain and why?

Answer 28

MRI - good for soft tissue and bone oedema and microfractures

Question 29

What are two presentations you should definitely investigate MRI?

Answer 29

Red flags or neurological signs/symptoms

Question 30

What are radionuclide bone scans useful for? (4)

Answer 30

Increased bone turnover (fractures, osteomyelitis, Paget’s, ank spond), Metastases, Tumours, osteoid osteoma

Question 31

Use of SPECT and PET scan for LBP?

Answer 31

Increased uptake in high turnover areas e.g. infection, malignancy

Question 32

When are laboratory tests indicated?

Answer 32

Any red flags, malignancy, infection, metabolic causes

Question 33

List 3 malignancy markers for LBP and what they test for

Answer 33

PSA and acid phosphatase - prostate cancer | Monoclonal bands - paraneoplastic syndrome

Question 34

List 4 metabolic lab tests for LBP?

Answer 34

Alk phos, Ca2+ (e.g. bony mets), PO4, HLA B-27

Question 35

What medication is good for relieving spasm?

Answer 35

Diazepam

Question 36

Pharmacological conservative treatment for LBP?

Answer 36

NSAIDS, opiates, gabapentin, TCAs, injections + physio

Question 37

What is the most effective prevention of back pain?

Answer 37

Physical activity

Question 38

What is management plan for sciatica?

Answer 38

Initially conservative unless red flags, may be for surgical intervention. Conservative because usually body resorbs disc material from disc bulge within 3 months

Question 39

What are 4 potential differentials for sciatica that are caused by root compression outside the spine?

Answer 39

Piriformis syndrome, Endometriosis, PID, Peroneal compression

Question 40

What are 4 potential differentials for radiculopathy symptoms that is not caused by root compression?

Answer 40

Arachnoiditis e.g. from previous haemorrhage, peripheral neuropathies, IIH can cause cervical compression symptoms, SI joint dysfunction