back pain

Question 1

back pain red flags

Answer 1

night pain
systemically unwell
progressive motor or sensory deficit
age <20 or >50yrs
history of malignancy
history of trauma

Question 2

suspected infection presentation

Answer 2

fever/chills
immunosuppression
IV drug use
dental status
foreign travel

Question 3

suspected fracture presentation

Answer 3

old lady
osteoporotic
significant trauma
chronic steroid use

Question 4

suspected cauda equina presentation

Answer 4

bilateral sciatica
urinary incontinence
decreased anal tone
loss of perianal sensation - saddle anaethesia

Question 5

suspected AAA presentation

Answer 5

age >60
abdominal pulsating mass
pain at rest

Question 6

suspected anylosing spodylitis presentation

Answer 6

young man with lower back pain + stiffness

stiffness worse in morning + improves with activity

Question 7

suspected peripheral arterial disease presentation

Answer 7

pain on walking, relieved by rest

absent or weak foot pulses + other signs of limb ischaemia

smoker, other vascular diseases

Question 8

suspected spinal stenosis presentation

Answer 8

gradual onset
uni/bilateral leg pain, numbness, weakness which is worse on walking
resolves when sits down
aching/craling pain
relieved by leaning forwards, crouching, sitting down

requires MRI to confirm diagnosis

Question 9

which test rules out sciatica

Answer 9

straight leg raise

sciatic nerve goes through femoral

Question 10

back pain investigations

Answer 10

most dont need, 70-90% resolve within a month

xray - only for young men (SIjoint to exclude ankylosing) or elderly (exclude collapse, fractures malignancy)

MRI - neurological signs

bone scan - osteomyeltis, pagets, metastases

Question 11

when to investigate

Answer 11

no improvement after 4-6wks
red flags

Question 12

patient presenting with signs of cauda equina

Answer 12

urgent MRI of lumbar spine

examine for sensitive dermatomes

commonest = L4/L5
-> effects lateral thigh, lateral calf + anterior calf

Question 13

WHO pain ladder

Answer 13

Nonopiod +/- adjuvant therapy
a. Paracetamol + NSAIDs

Weak opiod (+/- nonop or adj)
a. Codeine + tramadol

Strong opoids (+/- nonop or adj)
a. Morphine, oxycodone, fentanyl + buprenorphine

Question 14

adjuvant analgesics

Answer 14

= painkillers whose primary indication is for something other than pain

Anticonvulsants – gabapentin, pregabalin
Antidepressants – amitriptyline (tricyclic), duloxetine(SNRI)
o 1st line drug for neuropathic pain = amitriptyline (tricyclic antidepressant)
-> SE
* Constipation
* Dizziness
* Dry mouth