Multiprofessional Back Pain

Question 1

how can back pain refer to the leg?

Answer 1

can refer down the front via the femoral nerve

can refer down the back via the sciatic nerve

Question 2

important parts of history in back pain?

Answer 2

nature of the pain
degree of loss of function - how it impacts life
any trauma?
any previous surgery?
symptoms suggesting other pathology:
- urinary tract
- GI (pancreatitis)
- Resp (pneumonia)
- systemic illness

Question 3

general outline for spine exam?

Answer 3

Look
Feel
Move

Question 4

what do you look for?

Answer 4

scoliosis, kyphosis, scars etc

Question 5

what do you feel for?

Answer 5

spinal tenderness
paravertebral muscles
ask patient to show you where

Question 6

what movements do you check?

Answer 6

flexion, extension, lateral flexion
straight leg pain
tone, power, reflexes, sensation in legs

Question 7

how can back pain be investigated?

Answer 7

usually none
bloods: ESR, PV, Calcium, alkaline phosphatase (if suspicion)
rarely X rays
MRI - Often not what you see is what you get

Question 8

why is MRI better investigation than X ray?

Answer 8

most back problems are due to soft tissue problem

X ray only shows bone while MRI shows soft tissue

Question 9

when is an X ray indicated?

Answer 9

red flags present
significant trauma
known osteoporosis

Question 10

when is an MRI indicated?

Answer 10

sciatica > 4 weeks or spinal claudication

red flags

Question 11

how specific is MRI?

Answer 11

not perfect as many asymptomatic people can be shown to have bulging discs
- therefore MRI signs must match symptoms

Question 12

what are the radiological signs of osteoarthritis?

Answer 12

LOSS
loss of joint space
osteophyte formation
subchondral cysts
sclerosis

Question 13

what causes 90% of back pain?

Answer 13

mechanical/non-specific

Question 14

what are some less common causes of back pain?

Answer 14

tumour/metastases
ankylosing spondylitis
infection

Question 15

list 8 red flags for back pain?

Answer 15

age <20 or >60
thoracic pain
previous carcinoma
immunocompromise (steroids, HIV etc)
feeling unwell
weight loss
widespread neurological symptoms
structural spinal deformity

Question 16

list 9 yellow flags for chronic back pain

Answer 16

low mood
high levels of pain/disability
belief that activity is harmful
low education level
obesity
problem with claim/compensation
job dissatisfaction
light duties not available at work
lot of lifting at work

Question 17

what are some non medical management for back pain?

Answer 17

explanation
reassurance
encourage to mobilize
positive mental attitude

Question 18

what are some medical managements for back pain?

Answer 18

analgesia (paracetamol, opiates)
NSAIDs - short term
muscle relaxants - short term
physiotherapy
osteopathy and chiropractic
referral

Question 19

what is the main risk with NSAIDs and how can this be managed?

Answer 19

stomach/duodenal ulcer

co-prescribe omeprazole

Question 20

sciatica vs normal radiation of muscular back pain?

Answer 20

sciatica goes right down to the foot

muscular pain can radiate over buttocks/posterior thigh