Back Pain

Question 1

What are the 4 categories of back pain you should consider when taking a history from a patient with back pain?

Answer 1

• Simple mechanical backache
• Nerve root pain
• Serious spinal pathology
• Referred back pain

Question 2

Describe simple backache - nature of pain, who gets it, regions most commonly affected, prognosis

Answer 2

• Mechanical pain; varies with time and activity
• Most common in individuals aged 20-55
• Most common in lumbosacral region, buttocks and thighs
• Good prognosis; 90% better in 6 weeks

Question 3

Most presentations of back pain in general practice are mechanical. T/F

Answer 3

True

Question 4

What are the signs of nerve root pain?

Answer 4

• Unilateral leg pain is more common than back pain
• Pain radiates to the foot or toes, may be accompanied by numbness, weakness and parasthesia
• Motor, sensory or reflex changes in 1 or 2 nerve roots (dermatomes)

Question 5

What is the prognosis of nerve root pain?

Answer 5

Reasonable - 50% recover from an acute attack in 6 weeks

Question 6

Serious spinal pathologies: give an example of an emergency spinal pathology

Answer 6

Cauda equina syndrome

Question 7

What is cauda equnina syndrome?

Answer 7

Compression of the spinal nerve roots in the lumbar spine, leading to loss of sensation/ movement

Question 8

What are the symptoms of cauda equina syndrome?

Answer 8

• Saddle anaesthesia (anus, genitals, perineum)
• Difficulty urinating
• Loss of anal sphincter tone/ faecal incontinence
• Widespread/ progressive motor weakness in the legs
• Gait disturbance
• Loss of sensation in genitals during sexual activity

Question 9

How should cauda equina syndrome be managed?

Answer 9

Emergency decompression

Question 10

Serious spinal pathologies: give 4 examples of urgent spinal pathologies

Answer 10

• Tumours
• Spinal infection
• Inflammatory disorders
• Spinal deformity

Question 11

What are the symptoms of an inflammatory disorder of the spine?

Answer 11

• Gradual onset of limitation of spinal movement in all directions
• Marked morning stiffness lasting >30 mins
• Peripheral joint involvement
• Family history of ankylosing spondylitis or other seronegative disorders

Question 12

What movements of the spine should be examined?

Answer 12

Flexion, extension, lateral rotation

Question 13

Give an example of a sciatic nerve stretch you could use during examination

Answer 13

Straight leg raise

Question 14

What is sciatica?

Answer 14

Pain originating in the lower back and radiating down the leg due to irritation or compression of the sciatic nerve

Question 15

Describe the difference between referred leg pain and nerve root pain in the leg

Answer 15

Referred: dull pain, rarely below the knee

Nerve root: sharp/shooting pain, felt below the knee to foot and ankle (sciatica)

Question 16

What pathologies may present with referred back pain? (7)

Answer 16

• Peptic ulcer disease
• Gall bladder
• Pancreatic
• Renal
• Uterine/ovarian
• Colonic
• Aortic dissection (acute)

Question 17

Give an example of a femoral nerve stretch you could use during examination

Answer 17

Lie on side and bend the knee, pulling the foot up towards the bum

Question 18

Why is imaging rarely indicated in back pain?

Answer 18

Most people have varying degrees of degeneration in their spine so imaging does not provide good account of cause of back pain

Question 19

When would imaging be carried out? (3)

Answer 19

• If red flags of serious spinal pathology are present
• If surgery considered
• If persistent sciatica >4 weeks

Question 20

What are the red flags for serious spinal pathologies? (8)

Answer 20

• Age <20 or >50
• Thoracic pain
• History of cancer (breast, lung and prostate most likely to metastasise to bone)
• Immunocompromised (e.g., steroids, HIV)
• Systemic symptoms
• Weight loss
• Widespread neurological symptoms
• Structural spinal deformity

Question 21

What are the yellow flags for chronic back pain?

Answer 21

• Low mood
• High levels of pain/limitations of activity
• Obesity
• Interference with work

Question 22

What is the general management for back pain?

Answer 22

• Advise to remain active and exercise spine
• NSAIDs (1st line, short-term)
• Analgesics (paracetamol, short-term opiates if severe pain)
• Muscle relaxants (e.g., diazepam, only for a few days, can be very effective)
• Physiotherapy
• Refer (e.g., imaging, surgery)

Question 23

What mneumonic can help remember which cancers most commonly metastasise to bone?

Answer 23

Bad Boys Pee Through Kidneys:
Breast
Bronchus
Prostate
Thyroid
Kidneys

Question 24

What is the most common primary bone tumour?

Answer 24

Myeloma

Question 25

What is a gibbus?

Answer 25

An angular deformity of the thoracic spine