Back pain Flashcards
Back pain classification
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
Mechanical back pain/ LBP
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
Epidemiology mechanical pain
! 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.
Principles of assessment
• Symptoms
• Assess if nerve root irritation is present
• Nerve root irritation tests
• Document neurological signs
• Exclude cauda equina syndrome
Clinical features mechanical back pain
• 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
Prognosis for mechanical back pain
! Good
! 50% of patients are better within 1 week
! 90% better within 6 weeks
Recurrence of mechanical pain
• 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
Nerve Root Pain
• Unilateral leg pain > back pain • Radiation below knee
• Numbness and paraesthesia
• Nerve irritation signs
• Motor, sensory or reflex change – limited to one nerve root
Which nerve root?
! 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
Testing
Sciatic stretch test
Femoral leg stretch
Motor signs
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
L2
Hip flexion/adduction
L3
Hip adduction
Knee extension
Knee jerk
L4
Knee extension
Foot inversion/ dorsiflexion
Knee jerk
L5
Hip extension/abduction
Knee flexion
Foot/toe dorsiflexion
S1
Knee flexion
Foot/toe plantar flexion
Foot eversion
Ankle jerk
Epidemiology sciatica
! 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.
Prognosis for nerve root pain
! 50% of patients with nerve root pain are better within 6 weeks
NICE CG 59 – mechanical back pain/low back pain
! 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.
NICE recommendations
! 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
Why recommend physical activity for back pain?
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
What about the 10% who aren’t better at 6 weeks?
Nerve Back pain
• 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
Risk factors for chronic pain
• 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
Red Flags - possible serious pathology
• 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
