Back Pain

Question 1

How common is back pain?

Answer 1

49% to 70% of people will suffer low back pain

Most are better in a few days , 96% are better in six weeks

Question 2

How common is Sciatica?

Answer 2

5% to 10% of patients with low back pain have sciatica

2% of the population suffer sciatica in one year

Question 3

How is recovery for Sciatica patients?

Answer 3

60% recover from sciatica in three months

70% recover from sciatica in 12 months

30% continue to have sciatica for over one year

Question 4

Define Non-specific back pain

Answer 4

Pain not due to any specific/underlying disease that can be found

Question 5

Define Mechanical low back pain

Answer 5

Pain after abnormal stress and strain on the vertebral column

Question 6

Define sciatica

Answer 6

pain radiating to the lower limbs with or without neuralgic symptoms

Question 7

What are the mechanical causes of low back pain?

Answer 7

90% Mechanical
Disc degeneration Disc herniation Annular tears Facet joint OA Instability
Mechanical (90%)
Tumour including myeloma Infection Spondyloarthropathy Pars interarticularis injury Compression fracture Visceral

Question 8

What are non mechanical causes of back pain?

Answer 8

Tumour including myeloma Infection Spondyloarthropathy- all have a specific treatment
Pars interarticularis injury Compression fracture Visceral

Question 9

What are the indicators for sciatica?

Answer 9

Unilateral leg pain greater than low back pain

 Pain radiating to foot or toes

 Numbness and paraesthesia in the same distribution

 Straight leg raising test induces more leg pain

 Localised neurology—that is, limited to one nerve root

Question 10

What are the NICE guidelines for imaging

Answer 10

1.1.4
Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.
1.1.5
Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.
1.1.6
Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.

Question 11

What are some conservative treatments for back pain?

Answer 11

Analgesia (Paracetamol) Anti-inflammatory drugs Manipulation
Acupuncture
Massage
Allow some time to pass

Bed rest does not result in faster recovery

Most patients get better spontaneously

Question 12

What are the red flags for imaging in low back pain?

Answer 12

Weight loss
Fever
Night pain
Under 19 years

Question 13

What are the red flags in leg pain?

Answer 13

Bowel or bladder dysfunction
Saddle anaesthesia
Profound neurological deficit

Question 14

What would an early diagnoses do if there was metastases?

Answer 14

Early diagnosis may not impact on prognosis
 Risk of catastrophic fracture and paralysis
 Onset of symptoms to referral median 3 months

Question 15

What would early diagnosis do if there was Inflammatory arthropathy?

Answer 15

Early diagnosis for effective treatment with biologics  Investigate under 35 years after 3 months pain

Question 16

What would early diagnosis do if there was Myeloma?

Answer 16

Early diagnosis will catch disease at a more easily treated stage
 Mean delay in diagnosis - interquartile range 84 to 306 days

Question 17

What would early diagnoses do in Tuberculosis of the spine?

Answer 17

Early diagnosis is essential to effective treatment  Mean delay in diagnosis - 4 to 11 months

Question 18

What are the investigations for low back pain?

Answer 18

primary - MRI

secondary - Radiographs, CT

Question 19

What are the benefits of radiographs?

Answer 19

Cheap

Readily available Traditional

Question 20

What are the negatives in radiographs?

Answer 20

Radiation

Overlook most important diseases

Question 21

What Pain therapy is offered?

Answer 21

Physical therapy
 Analgesia
 Facet injections
• local & steroid
• denervation
 Root block
 Epidural injection
 Neurostimulation

Question 22

How are Facet injections used?

Answer 22

Approach 
Oblique
 Posterior ( inject the posterior inferior extension of the joint)
 21g needle
 Local - Marcain 0.5% 1ml
 Steroid - Triamcinolone 20mg  One level at a time
 Follow up
 Inside or around the joint
www.stlukesradiology.org.uk Spine - Interventional

Question 23

How would you conduct root block

Answer 23

Contrast in root sheath
One ml. local only
Follow up
CT - guided

Question 24

How would you give an epidural anaesthetic?

Answer 24

Interlaminar
Transforaminal
Caudal

Question 25

What would surgery achieve for lower back pain?

Answer 25

Decompression of nerve root
Decompression of spinal stenosis
Disc replacement
Fusion