3: PIVD and mechanical backache

Question 1

What is a major aspect of the social history in someone with mechanical back pain?

Answer 1

Occupational history

Question 2

What are some neurological symptoms associated with back pain?

Answer 2

Numbness

Pins and needles

Weakness

Bowel / bladder changes? think cauda equina

Question 3

What are some red flag features of back pain?

Answer 3

Non-mechanical pain

Systemic symptoms (fever, nausea, weight loss, night sweats…)

New neurological symptoms

Saddle anaesthesia / bowel / bladder symptoms (cauda equina syndrome)

History of cancer

History of steroid use

Question 4

What is saddle anaesthesia?

Answer 4

Anaesthesia limited to buttocks, thighs and perineum

major symptom of cauda equina syndrome

Question 5

What does Schober’s method measure?

Answer 5

Lumbar spine flexion

Question 6

What is the reference point for Schober’s test?

Answer 6

Sacroiliac dimples

Question 7

What spinal movements is a patient asked to perform during a spine assessment?

Answer 7

Flexion

Extension

Lateral flexion

Question 8

What is assessed during a neurological examination re: the spine?

Answer 8

Myotomes

Dermatomes

Reflexes

Nerve irritation

Question 9

Which reflexes are tested during a neuro exam?

Answer 9

Knee jerk (L3/4)

Ankle jerk (L5)

Plantar reflex

Question 10

How is sciatica tested for?

Answer 10

Leg raise

Aims to irritate nerves causing leg pain

Question 11

What is the femoral stretch test used to elicit?

Answer 11

Upper leg nerve pain

Question 12

Which nerve is affected in sciatica?

Answer 12

Sciatic nerve

L4 - S3

Question 13

Are X-rays used to diagnose causes of back pain?

Answer 13

No, they usually don’t help much

Cause anxiety because irrelevant abnormalities will appear on the report

Question 14

What is the gold standard investigation for back pain?

Answer 14

MRI scan

Question 15

Which joints are commonly involved in back pain?

Which investigation can be done to check this?

Answer 15

Facet joints

Diagnostic facet injection with analgesia to see if symptoms improve

Question 16

What type of joint are facet joints?

Answer 16

Synovial joints

Question 17

What is sciatica?

Answer 17

Buttock / leg pain in dermatome of sciatic nerve with neurological disturbance

Question 18

What spinal pathology causes a variety of different diseases?

Answer 18

Disc prolapse

Question 19

What is the normal presentation of disc prolapse?

Answer 19

Episodic back pain

then

Leg pain and neuro symptoms (sciatica) affecting specific myotomes and dermatomes

Question 20

Is disc prolapse an medical emergency?

Answer 20

No, unless it’s cauda equina syndrome

Question 21

Do all disc prolapses require surgery?

Answer 21

No, most settle themselves

Question 22

At what age do people tend to get disc prolapses?

Answer 22

30s - 50s

So if it’s not settling within 3 months it’s likely to severely disrupt their life

Question 23

If a patient’s disc prolapse isn’t resolving within 3 months, what is the next step?

Answer 23

Spinal surgery

Question 24

How is backache treated conservatively?

Answer 24

Bed rest for a short time

Simple analgesics, NSAIDs and muscle relaxants

Then mobilise the patient, physiotherapy, pain clinic, complementary therapy

Question 25

How many patients with back pain are suitable for surgery?

Answer 25

Very very few

Question 26

What is a progressive complication of facet fusion surgery?

Answer 26

Adjacent segment disease

Fusion spreads up to multiple levels - increasingly poor flexibility

Question 27

Factors like diagnosis, patient health and demographic actually matter little in terms of adverse factors for spinal surgery.

What are some significant adverse factors?

Answer 27

Yellow flags of back pain:

Patient is undergoing litigation

Disputes with government re: benefits

Chronic pain syndrome / behaviour