Back complaint

Question 1

Most common cause of low back pain presenting to GP

Answer 1

Vertebrae dysfunction due to mechanical back pain or back strain injury (72%), Lumbar spondylosis 10%

Question 2

Differentials of lower back pain

Answer 2

vertebral dysfunction
Lumbar spondylosis
Depression
UTI
Spondylolisthesis
Spondyloarthropathies
Musculoligamentous strain/tears
Malignant disease
arterial occlusive disease

Question 3

Probability diagnosis

Answer 3

vertebral dysfunction especially facet joint and intervertebral disc (mechanical)
Musculoligamentous strain/sprain
spondylosis - degenerative OA

Question 4

Serious disorders not to be missed when Dx back pain

Answer 4

Cardiovascular
ruptured aortic aneurysm
Retroperitoneal haemorrhage (anticoagulant)
Neoplasm
myeloma
Metastases
Severe infection
vertebral osteomyelitis
epidural abscess
Septic disci tis
Tuberculosis
pelvic abscess/PID
Osteoporotic compression fracture
Cauda equina compression

Question 5

Pitfalls in Dx of Back pain

Answer 5

Spondyloarthropathies
- ankylosing spondylitis
- reactive arthritis
- psoriasis
- bowel inflammation
Sacroiliac dysfunction
Spondylolisthesis 
Claudication
- vascular
- neurogenic/spinal canal stenosis
Paget disease
prostatitis
Endometriosis

Question 6

Seven masquerades of low back pain

Answer 6

Depression
spinal dysfunction
UTI

Question 7

Could your pt be trying to tell you something when presenting with back pain?

Answer 7

Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction

Question 8

When to consider a psycogenic cause of back pain?

Answer 8

abnormal illness behaviour 
compensation issues 
unsatisfactory restoration of activities 
failure to return to work 
unsatisfactory response to treatment 
treatment refused 
atypical physical signs

Question 9

Continuous pain

Answer 9

neoplasia or infection

Question 10

Pain on waking

Answer 10

inflammation or depressive illness

Question 11

Worse with activity but relieved by rest

Answer 11

mechanical dysfunction

Question 12

Worse with rest and relieved by activity

Answer 12

typical inflammation

Question 13

Pain aggravated by standing or walking that is relieved by sitting

Answer 13

spondylolisthesis

Question 14

Aggravated by sitting and improved with standing

Answer 14

Discogenic problem

Question 15

Pain of calf that travels proximally with walking

Answer 15

Vascular claudication

Question 16

Pain in buttock that descend when walking

Answer 16

Neurogenic claudication (older people with tendency to spinal canal stenosis associated with spondylosis.

Question 17

aching throbbing pain

Answer 17

Inflammation eg sacroilitis

Question 18

Deep aching diffuse pain

Answer 18

referred pain e.g. dysmenorrhoea

Question 19

Superficial steady diffusa pain

Answer 19

local pain e.g. muscular strain

Question 20

Boring deep pain

Answer 20

bone disease e.g. neoplasia, paget disease

Question 21

Intense sharp or stabbing (superimposed on a dull ache)

Answer 21

radicular pain eg sciatica

Question 22

Differences between typical inflammatory caused back pain from mechanical cause back pain

Answer 22

History - Inflammatory is insidious onset where mechanical is precipitated by injury/previous episodes
Nature - inflammatory is aching/throbbing where mechanical is deep dull ache, and sharp is root compression
Stiffness - Inflammatory is prolonged severe morning stiffness vs mechanical which is moderate and transient.
Effect of rest - inflammatory is exacerbated vs mechanical is relieved.
Effect of activity - opposite of above
Radiation - inflammatory is more localised, bilateral or alternating vs mechanical which tends to be diffuse or unilateral
Intensity - inflammatory is night or early morning vs mechanical which is end of day or following activity

Question 23

Questions to ask on hx

Answer 23

What is your general health like?
Can you describe the nature of your back pain?
Was your pain brought on by an injury?
Is it worse when you wake in the morning or later in the day?
How do you sleep during the night?
What effect does rest have on the pain?
What effect does activity have on the pain?
Is the pain worse when sitting or standing?
What effect does coughing or sneezing or straining at the toilet have?
What happens to the pain in your back or leg if you go for a long walk?
Do you have a history of psoriasis, diarrhoea, penile discharge, eye trouble or severe pain in your joints?
Do you have any urinary symptoms?
What medication are you taking? Are you on anticoagulants?
Are you under any extra stress at work or home?
Do you feel tense or depressed or irritable?

Question 24

What to look for on examination

Answer 24

Joint examination - look, feel, move , test function. determine symptoms and detect level of flexion
Neurological examination if symptoms below buttocks
Rectal examination if indicated
Screening test - slump test

Question 25

What are you looking for on general exception of back?

Answer 25

gait, standing (significant disc lesion) vs sitting, moves when thinking your not watching. general contour and symmetry of the back and legs, including the buttock folds, and look for muscle wasting lumbar lordosis and any abnormalities, such as lateral deviation ( usually away from the painful side.) midline moles, tufts of hair or haemangioma that might indicate an underlying congenital anomaly, such as spina bifida occulta.

Question 26

What active movements to do on examination

Answer 26

``` forward flexion (to reproduce the patient’s symptoms) 75-90° extension (to reproduce the patient’s symptoms) 20-30° lateral flexion (R & L) (to reproduce the patient’s symptoms) 30° ```

Question 27

When and what is slump test?

Answer 27

indicated for pt with low back pain with pain extending into leg and especially for post thigh pain. Positive if reproduce the pain Method: 1  The patient sits on the couch in a relaxed manner. 2  The patient then slumps forward (without excessive trunk flexion), and then places the chin on the chest. 3  The unaffected leg is straightened. 4  The affected leg only is then straightened (see Fig. 39.5). 5  Both legs are straightened together. 6  The foot of the affected straightened leg is dorsiflexed. Note: Take care to distinguish from hamstring pain. Deflexing the neck relieves the pain of spinal origin, not hamstring pain.

Question 28

What to palpate on examination

Answer 28

(to detect level of pain). Centrally, unilateral (right and left sides), transverse pressure to sides of spinous process R&L.

Question 29

What to look for in a neurological examination of lower back pain

Answer 29

Pain, paraesthesia, anaesthesia and weakeness that extends to the legs

Question 30

How to test for L3

Answer 30

Femoral stretch test, prone, flex knee, extend hip, Motor - extension of knee, Reflex Knee jerk, sensory anterior thigh

Question 31

How to test for L4

Answer 31

Motor - resisted inversion foot, Reflex Knee jerk, | Sensory inner border of foot to great toe.

Question 32

How to test for L5

Answer 32

Motor - extensor hallucis longus, no reflex, sensory on dorsum of foot, middle 3 toes

Question 33

how to test S1

Answer 33

Motor - Peroneus longus +brevis, Reflex - achillis tendon, sensation on back of heels/sole

Question 34

General management of lower back pain - acute

Answer 34

Beneficial advice to stay active NSAIDs likely to be beneficial analgesics spinal manipulation/stretching (reduced period of morbidity) unknown—back exercises, trigger point injections, acupuncture

Question 35

General management of lower back pain - chronic

Answer 35

For chronic low back pain (pain >12 weeks): beneficial—back exercises, multidisciplinary treatment program likely benefit—analgesics, NSAIDs, trigger point injections, spinal mobilisation/manipulation

Question 36

Big primary malignancy that cause back pain

Answer 36

Multiple myeloma

Question 37

Typical history of vertebral dysfunction causing lower back pain

Answer 37

age - late teens to old age usually 22-55yr Hx of injury of a lifting or twisting nature. Site and radiation - unilateral lumber but may be central. Refer over sacrum, SIJ areas and buttocks Type of pain - Deep sching pain, episodic Aggravation by activity, lifting, gardening, housework (vacuuming, making beds, etc) Reliefed by - rest and warmth Associated features - may be stiffness, usually good health.

Question 38

Typical examination findings in Vertebrae dysfunction causing lower back pain

Answer 38

Look Felt - Localised tenderness - unilateral or central, L4, L5 or S1 levels, Move - may be restricted flexion, extension, lateral flexion

Question 39

Dx pt that presents with Saddle anaesthesia (around anus, scrotum or vagina) Distal anaesthesia Evidence of UMN or LMN lesion Loss of sphincter control or urinary retention Progressive weakness of legs peripherally and areflexia (often bilateral)

Answer 39

Spinal cord (UMN) or cauda equina (LMN) compression. Surgical emergency Very rare

Question 40

Dx of pt with Anaesthesia or paraesthesia of the leg Foot drop Motor weakness Absence of reflexes

Answer 40

large disc protrusion, paralysing nerve root. | Uncommon and probable surgical emergency

Question 41

Dx of patient with Distal pain with or without paraesthesia Radicular pain (sciatica) Positive dural stretch tests

Answer 41

Posterolateral disc protrusion on nerve root or disc disruption Common

Question 42

Dx of pt with Lumbar pain (unilateral, central or bilateral) | +/- buttock and posterior thigh pain

Answer 42

Disc disruption or facet dysfunction or unknown (non-specific) causation very common

Question 43

Mx of vertebrae dysfunction

Answer 43

Education about diagnosis Activity directed by degree of pain but normal activity encouraged from out set Exercise program and swimming as tolerated (conflicting evidence on efficacy) Physical - Back education program Management - What, success rates, AE, Benefits, follow up Conversative - refer to education Activity directed by degree of pain but normal activity encouraged from out set - good evidence Exercise program and swimming as tolerated (conflicting evidence on efficacy) Physical therapy - for persistent problems but conflicting evidence Mobilisation Manipulation - good evidence on reducing period of morbidity unknown evidence lacking in back exercises, trigger point injections and acupuncture Medical Analgesics - paracetamol, and consider NSAIDs if inflammatory pattern present (good evidence)

Question 44

Mx for chronic low back pain due to vertebral dysfunction

Answer 44

Ix - consider a plain X-ray, ESR, Urine analysis, PSA (male and >50yr) Back education Normal activity Analgesics or paracetamol NSAIDs for 14 d if inflammatory Exercise program Trial of manipulation (if untrieed) x 3 if not indications Referral to physiologist Consider amitriptyline (tricyclic) at night start low and increase

Question 45

Mx for acute Sciatica with or without low back pain

Answer 45

``` Explanation and reassurance Back education program Resume normal activities ASAP Prescribed exercises - Walking, swimming Analgesia Regular non-opioid analgesics with review as the pt mobilised NSAIDs 14 days If severe unrelieved pain add tramadol or oxycodone for short term use Consider steroids for acute severe pain Rv wk or 2wkly ```

Question 46

Typical features of low back pain due to lumbar spondylosis. (degenerative osteoarthritis or osteoarthosis). Symptoms and signs

Answer 46

>50 yr old dull nagging Low back pain Stiffness especially in the morning (main feature) Pain at rest. aggravated by heavy activity, bending eg gardening, Relief by gentle exercise, hydrotherapy O/E All movements restricted Systemic - common joints affect are DIP (Heberden's nodes) and thumb carpe-metacarpal joints and knees. Most have tender joint and other joint affected e.g. PIP (Bouchard's nodes) mild synovitis

Question 47

Mx of Lumbar spondylosis (OA)

Answer 47

Education Exercises - improve muscle strength and joint stability Keep active Health BMI

Question 48

Standard mx of acute back pain without red flags

Answer 48

``` Education and encouragment -most are self limiting Back education program Address Psychoscoial issues Encouragement of normal daily activity including work, according to degree of comfort Analgesia - basics return to activity ASAP Avoid precipitants Physical therapy - stretching of affected segment, muscle energy therapy, spinal mobilisation or manipulation Prescribe exercises Refer to physiotherapy if not improving RV in 5 days No Ix needed ```

Question 49

Causes of back pain in 15-30 yr old

Answer 49

``` Prolapsed disc Trauma fractures Ankylosing spondylitis Spondlyolisthesis Pregnancy ```

Question 50

Causes of back pain in 30-50yr

Answer 50

Degenerative spinal disease Prolapsed disc Malignancy

Question 51

Causes of back pain in >50yr

Answer 51

``` Degenerative osteoporotic vertebral collapse Paget;s Malignancy Myeloma Spinal stenosis ```

Question 52

Symptoms of Ankylosing spondylitis

Answer 52

ankylosing spondylitis the pain is usually situated over the sacroiliac joints and lumbar spine; Radiates to buttock and hips worse at night associated with morning stiffness. typically better with activity, which helps distinguish it from mechanical back pain. Enthesitis = inflammation over site of insertion of tendon or ligament into bone eg achilles tendonitis, costochonditis, plantar fasciitis Dactylitis - Sausage digits due to soft tissue oedema and tenosynovial and joint inflammation Extra-articular manifestation Iritis - may cause blindness psoriaform rashes, oral ulcers, aortic valve incompetence Inflammatory bowel disease

Question 53

Signs of Ankylosing spondylitis

Answer 53

GI Rash -psoriaform Vital Back Inspect - loss of lumbar lordosis and thoracic kyphosis, severe flexion deformity of lumbar spine, palpate - tenderness of lumbar vertebrae, Move - reduction of movement of lumbar spine in all direction Measure - occiput to wall distance (increase distance =worsening), Schober’s test and lateral movement of spine - run hand straight down the side of each leg in turn = often severely restricted. Legs - insect Schilles endinitis, plantar fasciitis and signs of cauda equine compression - lower limb weakness, loss of sphincter control, saddle sensory loss resp - Decrease chest expansion

Question 54

Ix for Ankylosing spondylitis

Answer 54

``` Diagnosis is clinical Xray - feature appear late. Sacroiliitis is earliest sign. Vertebral syndesmophytes leading to ankylosis Calcification ligaments FBC - normocytic anaemia Increase ESR increase CRP HLA B27 ```

Question 55

Mx of ankylosing spondylitis

Answer 55

Exercise not rest. eg badminton, swimming or intense exercise to maintain posture and mobility Physiotherapy Anagelsia - NSAIDs (releive pain and slow progression) TNF alpha blocker - etanercept and adlimumab - when NSAID fail Local steriod injection Refer to Rheumatologist surgery - hip replacement Mortality - 1.5-4 X eg secondary amylidosis and heart disease.

Question 56

Signs and symptoms of spondylolisthesis

Answer 56

``` Pain worse on prolonged standing, walking and exercising. sign Stiff waddling gait increase lumbar lordosis Flexed knee stance Tender prominent spinous process of slipped vertebrae limited flexion hamstring tightness or spasm ```

Question 57

Diagnosis of spondylolisthesis

Answer 57

Lateral Xray standing

Question 58

Mx of spondylolisthesis

Answer 58

strict flexion exercise program for at least 3 months to aim at splint their own spine by strengthening abdo and spinal muscles Avoid extension of spine Gravity traction might help or corset

Question 59

Mx of chronic Sciatica with or without low back pain

Answer 59

Reassurance that problem will subside - assuming no severe neurological defect Consider epidural anaesthesia Consider amitriptyline

Question 60

Prevention of further back pain

Answer 60

education about back care Golden rules to live by - how to lift, sit, bend, play sport and so on. An exercise program Posutre and movement trainmen