Back pain

Question 1

What are primary causes of back pain?

Answer 1

1- Lumbosacral strain (mc)
2- Spondylosis (arthritis)
3- Disc herniation
4- Anatomic deformity (Scoliosis)
5- Spinal stenosis
6- Compression fractures (trauma, osteoporosis)

Question 2

What are systemic disease that causes back pain?

Answer 2

1- Infections (epidural abscess, osteomyelitis)
2- Metastasis (cancers)
3- Inflammatory back pain (ankylosing spondylitis, reactive arthritis)

Question 3

What pain can refer to the back causing back pain?

Answer 3

1- Pancreatitis or pancreatic psuodocyst
2- Kidney stones or pyelonephritis
3- Aortic dissection or aneurysms
4- Retroperitoneal hemorrhage

Question 4

What are the red flags in back pain?

Answer 4

1- Age > 50
2- History of cancer or unexplained weight loss
3- Failure to improve with therapy
4- Fever
5- Immunosuppression
6- Focal midline tenderness
7- Known or suspected bacteremia
8- IV drug use
9- Indwelling venous catheter
10- Prolonged steroids use, anticoagulants

Question 5

What are the special two tests in back examination?

Answer 5

1- Straight leg raise
2- Crossed straight leg raise
* Abnormal in disc herniation

Question 6

A patient with back pain that is worse with movement and improves with rest.
O/E: diffuse tenderness, no other findings.
Dx?

Answer 6

Lumbosacral strain
* no need for imaging
* Tx: paracetamol or NSAIDs

Question 7

An obese patient with acute back pain, radiate to ONE leg, worsens with sitting, improve with back extension.
O/E: decreased patellar or ankle reflex, abnormal straight leg raise.
Dx?

Answer 7

Disc herniation.
* RF: male, smoker, occupation, obesity
* Typical age: 30-55
* Tx: conservative: NSAIDs

Question 8

60 year old patient with back pain and leg pain that is more severe, worsen with standing, improves with sitting, associated with paresthesia and weakness in legs.
O/E: symptoms induced by asking patient to bend backwards, wide base gait.
Dx?

Answer 8

Spinal stenosis
* Secondary to spondylosis
* MRI to confirms Dx
* Conservative Tx (NSAIDs)
* Physiotherapy
* Surgical consultation (non-urgent)

Question 9

A patient with back pain that is worse in the morning, improves with movement, wakes patient up at night. He also suffers from morning stiffness in his PIPs that also improves with movement. The patient also has dry eyes and IBD.
O/E: decreased ROM, and nodules on PIP joints on hand.
Dx?

Answer 9

Spondylarthritis
* Test of autoantibodies
* X-rays for sacroiliac joints and lumbar spine
* Tx: NSAIDs, DMARDs
* Consult rheumatology
* Physiotherapy

Question 10

A 70 year old female patient who fell on her back suffering from back pain that worse by movement.
O/E: midline point tenderness on L3.
Dx?

Answer 10

Compression Fractures
* RF: trauma, osteoporosis, prolonged steroids use.
* Major RF: Hx of cancer
* +/- neurological defects below lesion
* X-rays
* Urgent neurosurgery consultation
* Tx: depends.

Question 11

RAPRIOP?

Answer 11

1- Reassure patient (sciatica takes a long time to heal)
2- Advice to avoid weight lifting, avoid prolong sitting, low-stress-aerobic exercises, weight reduction, proper posture
3- Paracetamol, NSAIDs
4- Referral to physiotherapyt
5- Investigation: depends
6- Follow up if symptoms didnt improve
7- Prevention depends on age, gender