Back pain

Question 1

Red flags

Answer 1

• Age less than 18 and more than 55 yrs old
• Night pain at rest
• Previous hx of infection or Ca
• Systemic symptoms
• Cauda equina symptoms
• Widespread neurology
• Thoracic back pain
• Steroid or IVDU

Question 2

How long do you have to be taking steroid for

Answer 2

Oral steroids for 3 months, not including inhalers

Question 3

Yellow flag signs

Answer 3

Psychosocial factors associated with poorer outcomes

• fear avoidance - reduce activity in fear it will make back worse
• whiplash or work claim
• negative attitude that back pain is harmful and will not get better
• unwillingness to do physio, wanting a quick fix
• low mood and social withdrawal

Question 4

Causes of back pain

Answer 4

Mechanical:

• Strain/idiopathic
• Trauma
• Pregnancy
• Disc prolapse
• Spondylolisthesis

Degenerative: spondylosis, vertebral collapse, stenosis

Inflammatory: Ankylosing spondylitis

Neoplasm: Mets, myeloma

Infection: TB, abscess

Question 5

Spondylolisthesis

Answer 5

Forward shift of one vertebra on another

Question 6

Common places of disc prolapse

Answer 6

L4/L5

L5/S1

Question 7

Nerve root lesions

Answer 7

L2:
- Hip flexion + adduction

L3

• Knee extension
• Hip adduction
• Reflex = Knee Jerk

L4:

• Foot inversion + dorsiflexion
• Knee extension
• Knee Jerk

L5

• Great toe dorsiflexion
• Foot inversion + dorsiflexion
• Knee Flexion
• Hip extension + abduction

S1

• Foot eversion
• Foot and toe plantarflexion
• Knee flexion
• Ankle Jerk

Question 8

Ix of back pain

Answer 8

Usually only necessary if red flags present:

Bloods: FBC, ESR, CRP
ALP, PSA - mets

MRI - of whole spine

CT - fracture

Question 9

Conservative Mx of back pain

Answer 9

• Max 2d bed rest
• Education: keep active, how to lift / stoop
• Physiotherapy - strengthen core muscles
• Psychosocial issues re. chronic pain and disability
• hot water bottle

Question 10

Medical mx of back pain

Answer 10

Analgesia:
NSAIDs ± co-codamol

(opiods do not help)

Amitriptyline for neurological pain and sciatica

Muscle relaxant: low-dose diazepam (short-term)

Facet joint injections - steroid and pain relief

Question 11

Surgical mx

Answer 11

Decompression

Prolapse surgery: e.g. microdiscectomy

Question 12

Cauda equina symptoms

Answer 12

Painless urinary retention 
Bilateral sciatica 
Faecal and urinary incontinence 
Impotence 
Perianal numbness

Question 13

Cancers that metastasise to spine

Answer 13

Prostate 
Breast 
Kidney 
Thyroid 
Lung

Question 14

Infection of spine

Answer 14

Sharp intense back pain commonly after UTI
Caused by spondylodiscitis

RF: IVDU and steroids

Question 15

Cauda equina

Answer 15

Group of lumbar and sacral spinal nerve roots that exit the spinal cord at L2

Question 16

Cauda equina syndrome

Answer 16

Compression of the cauda equina commonly due to paracentral disc prolapse

Occurs in 30 - 50s

Decompress within 48 hours

Question 17

Cauda equina syndrome presentation if not decompressed

Answer 17

Foot drop - L5
Manual evacuation and timed bowel movements
Catheter
Sexual dysfunction

Question 18

UMN legion

Answer 18

Pathology in brain or spinal cord

Question 19

UMN legion presentation

Answer 19

Hypereflexia
Spasticity 
Clasped knife rigidity 
Atrophy of disuse
Clonus - 5+ involuntary muscle spasms 
(Hoffman's in upper limb)
Babinski's sign

Question 20

Hoffman’s sign

Answer 20

Flick middle finger

Causes index finger DIP and thumb interphalangeal joint to flex

Question 21

LMN lesion

Answer 21

Legion at ventral horn or brainstem and below

Question 22

Presentation of LMN lesion

Answer 22

Fasciculations 
Paralysis 
Hypotonia
Hyporeflexia 
Atrophy of denervation

Question 23

Myelopathy

Answer 23

Conditions that affect the spinal cord

• stenosis
• normally cervical or lumbar

Question 24

Cervical myelopathy

Answer 24

60+ yo
Due to degeneration so progressively get worse
- paraesthesia of hand and arm
- loss of fine motor movements - can’t do buttons
- Loss of balance
- Decreased ROM and cervical neck pain due to OA

Mx: requires surgery

Question 25

Radiculopathy

Answer 25

Compression of nerve roots

Sensory, motor or mixed

Question 26

Bladder scan

Answer 26

Pre void and post void

Bladder normally holds 500ml

If retention:
Pre void - 400ml + residual
Post void - 200ml + residual

Question 27

Spondylodiscitis on Xray

Answer 27

Takes 3 -4 weeks to show end plate changes on Xray therefore not usually done