Back complaint Flashcards
Most common cause of low back pain presenting to GP
Vertebrae dysfunction due to mechanical back pain or back strain injury (72%), Lumbar spondylosis 10%
Differentials of lower back pain
vertebral dysfunction Lumbar spondylosis Depression UTI Spondylolisthesis Spondyloarthropathies Musculoligamentous strain/tears Malignant disease arterial occlusive disease
Probability diagnosis
vertebral dysfunction especially facet joint and intervertebral disc (mechanical)
Musculoligamentous strain/sprain
spondylosis - degenerative OA
Serious disorders not to be missed when Dx back pain
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
Pitfalls in Dx of Back pain
Spondyloarthropathies - ankylosing spondylitis - reactive arthritis - psoriasis - bowel inflammation Sacroiliac dysfunction Spondylolisthesis Claudication - vascular - neurogenic/spinal canal stenosis Paget disease prostatitis Endometriosis
Seven masquerades of low back pain
Depression
spinal dysfunction
UTI
Could your pt be trying to tell you something when presenting with back pain?
Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction
When to consider a psycogenic cause of back pain?
abnormal illness behaviour compensation issues unsatisfactory restoration of activities failure to return to work unsatisfactory response to treatment treatment refused atypical physical signs
Continuous pain
neoplasia or infection
Pain on waking
inflammation or depressive illness
Worse with activity but relieved by rest
mechanical dysfunction
Worse with rest and relieved by activity
typical inflammation
Pain aggravated by standing or walking that is relieved by sitting
spondylolisthesis
Aggravated by sitting and improved with standing
Discogenic problem
Pain of calf that travels proximally with walking
Vascular claudication
Pain in buttock that descend when walking
Neurogenic claudication (older people with tendency to spinal canal stenosis associated with spondylosis.
aching throbbing pain
Inflammation eg sacroilitis
Deep aching diffuse pain
referred pain e.g. dysmenorrhoea
Superficial steady diffusa pain
local pain e.g. muscular strain
Boring deep pain
bone disease e.g. neoplasia, paget disease
Intense sharp or stabbing (superimposed on a dull ache)
radicular pain eg sciatica
Differences between typical inflammatory caused back pain from mechanical cause back pain
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
Questions to ask on hx
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?
What to look for on examination
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
