Back pain

Question 1

Back pain classification

Answer 1

Non-inflammatory
◦ Mechanical / low back pain +/- sciatica
◦ OA
◦ Spinal stenosis
◦ Spondylolisthesis ◦ Scoliosis
◦ Vertebral fracture ◦ Etc

Inflammatory / serious pathology
◦ Infection eg. disciitis, osteomyelitis, abscess
◦ AxSpA
◦ Malignancy

Question 2

Mechanical back pain/ LBP

Answer 2

Other terms :
Back pain:
! Discogenic pain
! Degenerative disc disease
! Lumbar disc herniation
! Secondary to lumbar degenerative disease
! Facet joint pain

Sciatica
! Sciatica/lumbago
! Radicular pain/Radiculopathy
! Pain radiating to the leg
! Nerve root compression/irritation
! Neurogenic claudication
! Spinal stenosis

Question 3

Epidemiology mechanical pain

Answer 3

! Low back pain causes more disability, worldwide, than any other condition.
! Prevalence and burden increases with age until around the sixth decade, and worldwide prevalence has been reported to be highest in Western Europe.
! 19% of population in Europe report intrusive pain, and of these , 42% reported back pain
! Prevalence of back pain is more common in women than men, and increases with age peaking around the 7th decade.

Question 4

Principles of assessment

Answer 4

• Symptoms
• Assess if nerve root irritation is present
• Nerve root irritation tests
• Document neurological signs
• Exclude cauda equina syndrome

Question 5

Clinical features mechanical back pain

Answer 5

• 90% of all back pain
• Exact cause rarely identifiable: ligaments, muscles,
fascia, bursae, facet joints ,vertebral discs , sacroiliac joints
• Onset 20-55 yrs
• Lumbosacral, buttocks and thighs
• Pain worse towards end of day
• Patient is well

Question 6

Prognosis for mechanical back pain

Answer 6

! Good
! 50% of patients are better within 1 week
! 90% better within 6 weeks

Question 7

Recurrence of mechanical pain

Answer 7

• 60% will have a recurrence within 1 year
• Recurrent attacks tend to settle within 3 to 5 years
• Peaks in middle decades and becomes less frequent in later life

Question 8

Nerve Root Pain

Answer 8

• Unilateral leg pain > back pain • Radiation below knee
• Numbness and paraesthesia
• Nerve irritation signs
• Motor, sensory or reflex change – limited to one nerve root

Question 9

Which nerve root?

Answer 9

! 83% of prolapsed intervertebral discs will involve L5 or S1 roots

L5: 51%
S1: 22%
L5 and S1: 10%
L3 or L4: 17% (usually elderly)
! Spine 1981:6(2);175-179

Question 10

Testing

Answer 10

Sciatic stretch test
Femoral leg stretch

Question 11

Motor signs

Answer 11

L5
• weak dorsiflexion big toe
• weak dorsiflexion lateral 4 toes • weak eversion
S1
• absent ankle jerk
• weak gluteal contraction*
• weak knee flexion*
• weakness toe plantar flexion*
– *do not occur without absent ankle jerk

Question 12

L2

Answer 12

Hip flexion/adduction

Question 13

L3

Answer 13

Hip adduction
Knee extension

Knee jerk

Question 14

L4

Answer 14

Knee extension
Foot inversion/ dorsiflexion

Knee jerk

Question 15

L5

Answer 15

Hip extension/abduction
Knee flexion
Foot/toe dorsiflexion

Question 16

S1

Answer 16

Knee flexion
Foot/toe plantar flexion
Foot eversion

Ankle jerk

Question 17

Epidemiology sciatica

Answer 17

! Sciatica has a lifetime incidence ranging from 13 to 40%.
! The annual incidence of an episode of sciatica 1-5%.
! The incidence of sciatica is related to age - rarely seen before the age of 20, incidence peaks in the fifth decade and then declines.
! Modifiable factors associated with a first onset of sciatica include smoking, obesity, occupational factors and general health status.

Question 18

Prognosis for nerve root pain

Answer 18

! 50% of patients with nerve root pain are better within 6 weeks

Question 19

NICE CG 59 – mechanical back pain/low back pain

Answer 19

! Low back pain that is not associated with serious or potentially serious causes has been described in the literature as ‘non- specific’, ‘mechanical’, ‘musculoskeletal’ or ‘simple’ low back pain.
! The term ‘sciatica’ is used to describe leg pain secondary to lumbosacral nerve root pathology rather than the terms ‘radicular pain’ or ‘radiculopathy’, although they are more accurate. This is because ‘sciatica’ is a term that patients and clinicians understand, and it is widely used in the literature to describe neuropathic leg pain secondary to compressive spinal pathology.

Question 20

NICE recommendations

Answer 20

! Examine patient
! Do not refer for investigations unless high risk of poor
outcome
! Imaging in specialist settings of care only if the result is likely to change management.
! Educate to self-manage their low back pain with or without sciatica, and encourage to continue normal activities.
! Consider a group exercise programme

! Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage)
! Consider psychological therapies using a cognitive behavioural approach with exercise, with or without manual therapy
! Consider oral non-steroidal anti-inflammatory drugs (NSAIDs)
! Consider weak opioids (with or without paracetamol)
! Promote and facilitate return to work or normal activities of daily living

! Do not offer
◦ belts or corsets
◦ foot orthotics or rocker sole shoes
◦ traction
◦ acupuncture
◦ USS, percutaneous electrical nerve simulation, transcutaneous electrical nerve simulation (TENS), interferential therapy,
◦ Paracetamol alone, opioids, antidepressants or anticonvulsants

NICE approved interventions:
! Radiofrequency denervation: focused electrical energy heats and denatures the nerve with relief at least 6–12 months
! Epidurals/ nerve root injections
! Spinal fusion: Overall, no clear advantage of fusion but do show some modest benefit for some elements of pain, function and quality of life

Question 21

Why recommend physical activity for back pain?

Answer 21

Rest perpetuates disability
May relieve venous congestion and oedema
Muscular afferent activity may interfere with pain signal processing
Spinal movement may have a similar effect Precise form of exercise seems unimportant

Question 22

What about the 10% who aren’t better at 6 weeks?
Nerve Back pain

Answer 22

• Biological assessment
» nerve root problems?
» red flags?
» check CRP / L spine xray if relevant
• Psychological assessment » unjustified fears?
» depressed?
• Social assessment
» family relationships » work problems

Question 23

Risk factors for chronic pain

Answer 23

• Previous history of back pain
• Previous time off work
• Radicular pain
• Unfit
• Poor general health
• Smoking
• Depression / anxiety
• Disproportionate pain behaviour • Personal problems
• Medicolegal proceedings

Question 24

Red Flags - possible serious pathology

Answer 24

• Malignancy
• Corticosteroids
• Pt systemically unwell
• Wt loss
• Widespread neurology
• Age < 20yrs or >55yrs
• Violent trauma
• Constant, progressive, non - mechanical back pain • Thoracic pain
• IV drug abuse / HIV infection
• Persisting severe restriction of lumbar flexion
• Structural deformity

Question 25

Cauda Equina syndrome

Answer 25

• Large Central disc herniation compressing cauda equina (also tumours / abscesses)
• Bilateral sciatica
• Urinary / faecal incontinence
• Saddle anaesthesia
• Widespread (>one nerve root) or weakness in legs
O/E: rectal examination reveals reduced tone
URGENT MRI AND SPINAL SURGEON ASSESSMENT

Question 26

OA Spine

Answer 26

! OA
◦ Includes facet OA.
◦ Typically, pain is most pronounced first thing in the morning and then recurs as the joint has been stressed with exercise/weight bearing.

Question 27

Spinal stenosis

Answer 27

Elderly patients
LBP radiation to the legs with exercise
Worse after exertion and standing
Relieved by rest over 10 mins or so
Relieved by bending forward

Question 28

Spondylolysis and spondylolisthesis

Answer 28

! Spondylolysis
◦ Defect in pars intra-articularis, usually 5th neural arch
◦ Related to sport in teenager years
◦ Usually asymptomatic
◦ Can be associated with low back pain
◦ Oblique plain radiographs (MRI if neurological symptoms)
◦ Treatment is conservative

Question 29

Spondylolisthesis

Answer 29

! Spontaneous displacement of a vertebral body in relation to the vertebral body directly beneath it
! Usually displaced in an anterior direction
! Causes include spondylolysis, congenital malformation
and facet joint OA
! Neurological involvement can occur (less likely with OA)
! Treatment: conservative, rarely spinal fusion

Question 30

AxSPA

Answer 30

• Synovitis
• Enthesitis (inflammation of bony-ligamentous junctions)
• Ossification of enthesis especially the spine • HLA B 27 association

See lecture

Question 31

Infections

Answer 31

! Disciitis
! Osteomyelitis
! Epidural abscess

Question 32

Vertebral osteomyelitis and disciitis

Answer 32

! Haematogenous spread
! Original infection may not be identified
Clinical features:
! Insidious onset of pain
! Spinal tenderness
! 15% have symptoms and signs of nerve root compression
! Fever in less than 50%

Question 33

Investigations of spinal infection

Answer 33

! Inflammatory markers
! Blood cultures
! MR
! Culture biopsy yield of 50%
◦ Staph aureus and coagulase negative staph are commonest bugs

Question 34

Other levels may be involved

Answer 34

! Do whole spine MRI
! Other levels involved in up to 10%

Question 35

Classification – summary

Answer 35

! Non-inflammatory
◦ Mechanical / low back pain +/- sciatica
◦ OA
◦ Spinal stenosis
◦ Spondylolisthesis ◦ Scoliosis
◦ Vertebral fracture ◦ Etc
! Inflammatory / serious pathology
◦ Infection eg. disciitis, osteomyelitis, abscess
◦ AxSPA
◦ Malignancy