Lower back pain and sciatica

Question 1

What defines acute lower back pain?

Answer 1

Anything less than 6 weeks

Question 2

What should be evaluated in someone with LBP?

Answer 2

Determine is pain is intrinsic and not referred from elsewhere; AAA
Rule out life threatening disease; in children screen for cancer
Determine whether root compression is present

Question 3

General red flags in back pain?

Answer 3

Failure to improve after 4-6 weeks
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit

Question 4

Cancer red flags

Answer 4

Age >50
Unintended wt loss
Hx of ca
Pain at night and in recumbency

Question 5

Infection red flags

Answer 5

Fever/chills
Recent infection
Immunosuppression
IVDU
Dental status; 60-70% of brain and spinal abscesses have a dental origin
Foreign travel

Question 6

RF for #

Answer 6

Age >50
Osteoporosis
Significant trauma
Chronic steroid use

Question 7

Sy for CES

Answer 7

Bilateral sciatica
Urinary incontinence
Leg weakness
Absent anal tone
Loss of perianal sensation; most sensitive indicator

Question 8

Sy of AAA

Answer 8

Age >60
Male
Abdo pulsating mass
Pain at rest

Question 9

LL neurological exam

Answer 9

SLR
Muscle strength
Sensation; light touch, pin prick, vibration
Deep tendon reflexes

Question 10

Nerve root for flexion of hip

Answer 10

L2,3

Question 11

Nerve root for extension of hip

Answer 11

L4,5

Question 12

Nerve root for extension of knee

Answer 12

L3,4

Question 13

Nerve root for flexion of knee

Answer 13

L5,S1

Question 14

Nerve root fo plantarflexion

Answer 14

S1,2

Question 15

Nerve root for dorsiflexion

Answer 15

L4,5

Question 16

Nerve root for eversion

Answer 16

L4

Question 17

Nerve root for inversion

Answer 17

L5,S1

Question 18

Nerve root for shoulder abduction

Answer 18

C5

Question 19

Nerve root for shoulder adduction

Answer 19

C6,7

Question 20

Nerve root for elbow flexion

Answer 20

C5,6

Question 21

Nerve root for elbow extension

Answer 21

C7,8

Question 22

Nerve root for wrist flexion and extension

Answer 22

C6,7

Question 23

Nerve root for finger abduction

Answer 23

C8,T1

Question 24

Nerve root for finger flexion

Answer 24

C7,8

Question 25

Nerve root for finger extension

Answer 25

C7,8

Question 26

Nerve root for supination

Answer 26

C6

Question 27

Nerve root for pronation

Answer 27

C7,8

Question 28

When should you request an x-ray in LBP?

Answer 28

Young men; SI-joints to exclude ank spon | Elderly; exclude vertebral collapse, # or malignancy

Question 29

What is a CT good for in terms of localisation of pathology of the spine?

Answer 29

Bony pathology; trauma, tumour, infection Foreign bodies Implants Spinal fusion planning

Question 30

What is an MRI good for in terms of localisation of spinal pathology?

Answer 30

Soft tissue; tumours, infection Bone oedema Can see spinal cord MUCH better

Question 31

What modality of imagine should be used for spinal pathologies that have red flags or neurological si/sy?

Answer 31

MRI

Question 32

What will radionucleotide scans show?

Answer 32

Increased bone turnover; #, osteomyelitis, paget's, ank spon Mets Tumours; osteoid osteoma

Question 33

When should lab tests be utilised in LBP?

Answer 33

Malignancy; PSA, acid phosphate, monoclonal bands Infection Metabolic; alk phos, calcium, phosphate, HLA B-27

Question 34

When should LBP be investigated?

Answer 34

No improvement after 4-6 weeks | Red flags

Question 35

When should LBP be referred to secondary care?

Answer 35

Intractable pain Serious pathology suspected or suggested initial imaging Neurological deficit

Question 36

What are risk factors for back pain?

Answer 36

Previous back pain Heavy lifting/ frequent bending Repetitive work with exposure to vibration

Question 37

What is the most effective preventative measure for back pain?

Answer 37

Exercise

Question 38

What are differential diagnosis for sciatica?

Answer 38

Root compression by other degenerative disease: bony spurs, canal stenosis, spondylolisthesis, facet hypertrophy Root compression of sinister cause: tumour, fracture, TB Root compression from outwith the spine: piriformis syndrome, endometriosis, pelvic disease, peroneal compression (painless foot drop) No root compression: arachnoiditis, peripheral neuropathy

Question 39

What commonly causes an increase in pain with a disc prolapse?

Answer 39

Coughing Sneezing Twisting

Question 40

What are the examination signs of a L5/S1 disc prolapse?

Answer 40

Reduced forward flexion and extension (all disc prolapses) Calf pain Weak foot plantar flexion Reduced pin prick over sole of foot and back of cald Reduced ankle jerk

Question 41

Examination findings in an L4/L5 disc prolapse

Answer 41

Hallux extension weak | Reduced sensation on outer dorsum of foot

Question 42

What causes CES?

Answer 42

Central prolapse of lumbar disc

Question 43

When is a discectomy indicated?

Answer 43

CES Progressive muscular weakness Continuing pain

Question 44

What is spondylolisthesis?

Answer 44

Displacement of one lumbar vertebrae on another usually L5 on S1

Question 45

What can cause spondylothesis?

Answer 45

Spondylosis (age related degeneration with osteophyte formation) Congenital malformation OA of facet joints

Question 46

What causes lumbar spinal stenosis and lateral recess stenosis?

Answer 46

Generalised narrowing of lumbar spinal canal or its lateral recesses causing nerve ischaemia Facet joint OA and osteophytes

Question 47

What are the symptoms of spinal stenosis and lateral recess stenosis?

Answer 47

Pain worse on walking Pain on extension Negative SLR Few CNS signs

Question 48

Yellow flags for back pain

Answer 48

Belief that pian and subsequent activity are harmeful Pain behaviour Over-reliance on passive treatments Depression, anxiety, personality disorders Unsupportive home environment or over-protective family Inappropriate expectations and failing to actively engage with tx

Question 49

Typical causes of back pain in those 15-30yrs?

Answer 49

``` Prolapsed disc Trauma # Ank spon Spondylolisthesis Pregnancy ```

Question 50

Typical causes of back pain in those >30yrs?

Answer 50

Prolapsed disc | Malignancy (lung, breast, prostate, thyroid kidney)

Question 51

Typical causes of back pain in those >50yrs?

Answer 51

``` Degenerative disc Osteoporosis Paget's Malignant Myeloma Lumbar artery atheroma ```