Back Pain

Question 1

The location of back pain is usually related to the region of the vertebral column.

Low back pain (… region)
Mid-back pain (… region)
Upper back pain or neck pain (… region)

Answer 1

Low back pain (lumbar region)
Mid-back pain (thoracic region)
Upper back pain or neck pain (cervical region)

Question 2

The vast majority of back pain is located in which region?

Answer 2

The vast majority of back pain is located in the lower lumbar region known as low back pain

Question 3

The onset of back pain can be broadly divided based on acuity.

Acute: back pain < … weeks
Subacute: back pain for .. - .. weeks
Chronic: back pain for ≥ … weeks

Answer 3

Acute: back pain < 4 weeks
Subacute: back pain for 4 - 12 weeks
Chronic: back pain for ≥ 12 weeks

Question 4

The causes of back pain can be broadly divided into musculoskeletal, non-musculoskeletal, and … ….

Answer 4

The causes of back pain can be broadly divided into musculoskeletal, non-musculoskeletal, and referred pain.

Question 5

Back pain can be broadly divided into three categories:

Answer 5

Musculoskeletal (i.e. mechanical)
Non-musculoskeletal (i.e. non-mechanical)
Referred pain (i.e. from visceral organ)

Question 6

Despite numerous possible causes, a significant proportion of adults (> 85%) will not have an identified cause of their back pain. This is often described as ‘…’ and usually resolves within …

Answer 6

Despite numerous possible causes, a significant proportion of adults (> 85%) will not have an identified cause of their back pain. This is often described as ‘non-specific back pain’ and usually resolves within a few weeks.

Question 7

Musculoskeletal (mechanical) back pain causes (9)

Answer 7

Muscular
Degenerative discs
Spondylosis 
Spondylolisthesis
Spinal fracture
Spinal stenosis
Scoliosis
Sacroiliitis
Radiculopathy

Question 8

Muscular back pain:

Answer 8

Strain or sprain within the paraspinal lumbar muscles accounts for a significant proportion of low back pain. Often leads to intense pain for 24-48 hours. A strain is an injury to a muscle(s) or muscle-tendon(s) and a sprain is an injury to a ligament(s)

Question 9

Degenerative discs - back pain

Answer 9

herniation or bulging of the intervertebral discs can lead to back pain and discomfort. If the disc impingements on nerve roots it can lead to radicular pain (i.e. shooting pain along a nerve root) that passes into the leg.

Question 10

Spondylosis (i.e. osteoarthritis of the spine): this refers to …

Answer 10

this refers to degenerative arthritis affecting the spine that can cause aching, pain, or stiffness in the back

Question 11

Spondylolisthesis: this refers to …

Answer 11

this refers to one of the vertebral bones slipped out of alignment. It may be related to degenerative changes, trauma, or a stress fracture in the bone known as spondylolysis

Question 12

Spinal stenosis: this describes …

Answer 12

this describes narrowing of the spinal canal. Typically multifactorial due to spondylosis, spondylolisthesis, and/or ligament changes (e.g. ligamentum flavum hypertrophy). Classically causes back pain and lower limb claudication (i.e. leg pain/cramping on movement). The pain is differentiated from vascular lower limb claudication by the presence of paraesthesia-type pain that is worse with the back extended (e.g. going downhill) and relived on sitting/lying within minutes not immediately.

Question 13

Scoliosis: this refers to ..

Answer 13

this refers to lateral curvature of the spine.

Question 14

Sacroiliitis: this refers to …

Answer 14

this refers to inflammation of the sacroiliac joints that are commonly seen in ankylosing spondylitis. It is characteristically worse in the morning and better with exercise.

Question 15

Radiculopathy: refers to …

Answer 15

refers to symptoms or impairments related to the involvement of a spinal nerve root. Classically causes back pain and radicular pain felt in the distribution of the spinal dermatome.

Question 16

back pain in association with malignancy is commonly due to …

Answer 16

back pain in association with malignancy is commonly due to metastasis to the spine.

Question 17

As cancer deposited within the spine continues to grow it may damage surrounding structures lead to spinal instability and can lead to … compression or … … syndrome. Pain may also be from a primary boney tumour or s….

Answer 17

As cancer deposited within the spine continues to grow it may damage surrounding structures lead to spinal instability and can lead to cord compression or caudal equina syndrome. Pain may also be from a primary boney tumour or sarcoma.

Question 18

Epidural abscess: this may cause localised pain and fever. Depending on the size it may compress nerve roots leading to … or the spinal cord causing …. Usually, there is a history of an epidural, spinal injection, or adjacent soft tissue infection.

Answer 18

Epidural abscess: this may cause localised pain and fever. Depending on the size it may compress nerve roots leading to radiculopathy or the spinal cord causing compression. Usually, there is a history of an epidural, spinal injection, or adjacent soft tissue infection.

Question 19

Discitis: this refers to an infection of the intervertebral disc and is commonly due to a … infection. Commonly associated with iatrogenic line infections or endocarditis. Causes localised back pain.

Answer 19

Discitis: this refers to an infection of the intervertebral disc and is commonly due to a Staphylococcal infection. Commonly associated with iatrogenic line infections or endocarditis. Causes localised back pain.

Question 20

…: this refers to infection of the bone. Typically causes gradually worsening pain over weeks in association with fever and other constitutional symptoms. Many cases are healthcare-related due to bacteraemia following a procedure.

Answer 20

Osteomyelitis: this refers to infection of the bone. Typically causes gradually worsening pain over weeks in association with fever and other constitutional symptoms. Many cases are healthcare-related due to bacteraemia following a procedure.

Question 21

… arthropathy: many connective tissue disorders can affect the musculoskeletal structures of the spine leading to back pain.

Answer 21

Inflammatory arthropathy: many connective tissue disorders can affect the musculoskeletal structures of the spine leading to back pain.

Question 22

Pain felt in the back may be referred pain from a visceral organ. Some of these causes can be life-threatening so it is important to have a high index of suspicion. Classic examples include: (6)

Answer 22

Pancreatitis
Aortic dissection
Renal calculi
Ruptured aortic aneurysm
Pyelonephritis
Biliary colic

Question 23

Pancreatitis
Aortic dissection
Renal calculi
Ruptured aortic aneurysm
Pyelonephritis
Biliary colic

Can all cause pain where?

Answer 23

Back pain

Question 24

It is essential to exclude … or …. in patients with back pain.

Answer 24

It is essential to exclude spinal cord or cauda equina compression in patients with back pain.

Question 25

In simple terms, back pain with new neurological features may suggest spinal cord or cauda equina involvement and a full neurological examination with an inquiry about …/… function is essential.

Answer 25

In simple terms, back pain with new neurological features may suggest spinal cord or cauda equina involvement and a full neurological examination with an inquiry about bladder/bowel function is essential.

Question 26

Spinal cord compression

This refers to compression of the spinal cord anywhere along its course from the … magnum to the L../.. vertebrae. Spinal cord compression is commonly due to metastatic cancer or mechanical causes (e.g. unstable spinal fracture).

Answer 26

Spinal cord compression

This refers to compression of the spinal cord anywhere along its course from the foramen magnum to the L1/2 vertebrae. Spinal cord compression is commonly due to metastatic cancer or mechanical causes (e.g. unstable spinal fracture).

Question 27

Back pain is often the presenting feature. Cord compression is characterised by: (5)

Answer 27

Back pain (usually symmetrical and bilateral)
Bilateral leg weakness
Increased reflexes (upgoing planters, increased knee reflex)
Sensory level (the lowest spinal cord level that still has normal pinprick and touch sensation. Below this there is abnormal sensation. The level corresponds to the dermatomes)
Bladder/bowel dysfunction (late sign)

Question 28

Cauda equina syndrome - what is this?

Answer 28

This refers to compression of the cauda equina, which describes the collection of spinal nerves composed of lumbar, sacral, and coccygeal nerves beyond the terminal part of the spinal cord. Cauda equina syndrome is commonly due to malignancy or mechanical causes (e.g. disc disease, trauma).

Question 29

Caudal equina syndrome is characterised by:

Answer 29

Back pain (more asymmetrical and radicular)
Asymmetrical leg weakness
Reduced reflexes (downing planters, absent knee reflex)
Radicular sensory loss (dermatomal pattern)
Urinary retention
Reduced anal tone
Saddle anaesthesia

Question 30

What is saddle anaesthesia?

Answer 30

Saddle anaesthesia refers to reduced sensation in the area that would be in contact with a saddle if sitting on one.

Question 31

When evaluating back pain it is important to consider the …

Answer 31

When evaluating back pain it is important to consider the mechanism of injury.

Question 32

Constitutional symptoms - back pain

Answer 32

Fatigue
Fever
Weight loss
Night sweats
Myalgia/Arthralgia
Anorexia

They are associated with systemic diseases such as an underlying infection, inflammatory disorders, or cancer.