Back pain Flashcards
What are the 2 classes of back pain?
Non-inflammatory
Inflammatory with underlying pathology
Define mechanical back pain?
Lower back pain that arises from damage to spinal joints, vertebrae, discs or soft tissue due to physical forces
According to NICE, does mechanical back pain have an association with serious/potentially serious underlying causes?
No
How can degenerative disc disease cause mechanical back pain?
Degenerative disc disease causes discogenic pain (pain that arises from damaged intervertebral disc), which is a type of mechanical back pain
In which spinal region does disc herniation most commonly cause mechanical back pain?
Lumbar disc herniation
What is spondylosis, and how can it lead to mechanical back pain?
Spondylosis is spinal OA, which causes degenerative changes such as facet joint pain and stiffness
What percentage of all worldwide back pain cases are caused by mechanical back pain?
90% of all back pain cases
Which world region has the highest prevalence of mechanical back pain?
Western Europe
What percentage of Europeans have mechanical back pain?
42%
What is the normal age range of onset for mechanical back pain?
20-55 years
How does prevalence of mechanical back pain change with age?
Prevalence increases with age until 60s, then peaks around 70 years and declines
How does mechanical back pain present at different times in the day?
Mechanical back pain worsens throughout day and is worst at night
What 3 areas does pain radiate to when a patient has mechanical back pain?
Lumbosacral spine
Buttocks
Thighs
Does a patient with mechanical back pain present with systemic symptoms?
No, patient is generally well
When investigating mechanical back pain, what 3 factors must be assessed and documented?
Possible nerve root irritation
Any neurological signs
Any symptoms, so that CES can be excluded
What percentage of patients with mechanical back pain recover within a week?
50%
What percentage of patients with mechanical back pain recover within 6 weeks?
90%
What percentage of patients have recurrent mechanical back pain within a year?
60%
How long do recurrent attacks of mechanical back pain take to settle, and does their prevalence change with age?
Recurrent attacks settle within 3-5 years
Attacks peak in middle age and become less frequent as age increases
Define sciatica?
A type of radiculopathy of a sciatic nerve root, causing pain that originates along sciatic nerve
How is sciatica described instead of a type of radiculopathy, and why is this description of sciatica more commonly used?
More commonly described as leg pain secondary to lumbosacral nerve root pathology, because this more clearly understood by patients
83% sciatica cases arise from disc herniation of which 2 nerve roots?
Either L5 (51%) or S1 (22%)
What percentage of sciatica cases arise due to polyradiculopathy, and which 2 nerve roots are both affected?
10% cases
Both L5 and S1
Which 2 nerve roots are commonly affected in elderly patients that cause sciatica, and what percentage of all sciatica cases does this occur in?
17% cases affect L3 or L4, which typically occur in elderly patients
Can sciatica be a symptom of spinal stenosis?
Yes
What condition is sciatic commonly mistaken for?
Neurogenic claudication: Compression of nerve root in lumbar sacral spine that causes intermittent leg pain, fatigue, numbness
What percentage of the general population get sciatica in their lifetime (lifetime incidence)?
13-40%
What is the rate of annual incidence (new cases in a year) of a sciatica episode?
1-5%
What is the normal age range of onset of sciatica?
20-50, prevalence increases in age and reaches peak in 50s
Declines after 50s
In sciatica, where does the pain radiate to, and is it bilateral or unilateral?
Unilateral leg pain that radiates from lower back/buttocks and spreading down leg below knee
How does sciatic pain affect the muscles in the back?
Pain radiating from lower back to below knee causes lumbago (limited function of lumbar back muscles)
Give 2 examples of sensations in the leg caused by sciatica?
Numbness
Paraesthesia
How do you perform the sciatic stretch/straight leg raising (SLR) test, and what is the positive result?
Flex hip and raise straight leg, if patient feels pain below knee on posterior calf between 30 and 70 degrees hip flexion, the test is positive and suggests sciatica
How do you perform the femoral nerve stretch test, and what is the positive result?
Flex knee while patient is lying prone (face-down), if flexion causes anterior thigh pain test is positive and suggests nerve root impingement
What 2 special tests are performed to test for sciatica, and what are the indications of their positive results?
Femoral nerve stretch test positive result suggests nerve root impingement
Sciatic stretch/straight leg raising (SLR) test positive result suggests sciatica
How long does it take to recover from sciatica?
Many cases of sciatica recover within 4-6 weeks without treatment
Severe cases can take weeks-months to recover
How can enthesitis due to AxSpA lead to back pain?
Enthesitis in spinal ligaments and tendons causes ossification in response, which produces bony spurs which can compress nerves and nerve roots
When a patient has spondylosis, which vertebral structure has degenerated due to OA most commonly?
Facet joint OA
How does pain present throughout the day in spondylosis, and what exacerbates the pain?
Pain is worst at night and is exacerbated by exercise/weight-bearing as this stresses joint
Does spinal stenosis commonly occur in young or elderly patients?
Elderly patients
What 3 actions make leg pain caused by spinal stenosis worse?
Exertion
Exercise
Standing
What 2 actions relieve leg pain caused by spinal stenosis?
Resting for over 10 min
Bending forwards
Who do vertebral fractures most commonly affect, and describe the symptoms?
Commonly occurs in teenagers who play sports
asymptomatic but can be associated with low back pain
What is pars interarticularis?
Bony bridge between superior articular facet and inferior articular facet of a vertebral arch
Define spondylolysis?
Compression/stress fracture of pars interarticularis, but vertebral bodies aren’t displaced
Define spondylolisthesis?
Compression/stress fracture of pars interarticularis which causes vertebral body to be displaced anteriorly to one directly beneath
What radiological imaging is done to investigate a vertebral fracture?
Oblique plain radiograph
If patient has neurological symptoms then MRI is ordered
What is the primary method of treating vertebral fractures?
Conservative treatment
Spinal fusion is rare
How does vertebral osteomyelitis and discitis spread?
Haematogenous spread
Give 2 investigations to identify the original infection causing vertebral osteomyelitis and discitis?
Blood cultures
Check for inflammatory markers
Describe the onset and 3 symptoms of back pain caused by vertebral osteomyelitis and discitis?
Insidious onset
Spinal tenderness is common
15% have nerve root compression symptoms and signs
Less than 50% cases have fever
If a patient is suspected to have vertebral osteomyelitis and discitis, what region of their spine is imaged using MRI?
Whole spine MRI
Up to 10% cases affect multiple segmental levels
According to NICE, when should patients with non-inflammatory back pain be referred for further investigation?
High prognosis of poor outcome
According to NICE, when should patients with non-inflammatory back pain be referred for imaging?
Only if result is likely to change management
Give 2 activities that patients are encouraged and facilitated to continue in order to manage pain?
Normal hobbies and activities
Work
Give 2 examples of manual therapy for non-inflammatory back pain that are approved by NICE?
Massage
Spinal manipulation
What example of manual therapy for non-inflammatory back pain is not approved by NICE?
Accupuncture
Give an example of psychological therapy for non-inflammatory back pain that is approved by NICE?
CBT
Give 2 reasons why group exercise programmes and any physical activity is recommended by NICE for non-inflammatory back pain?
Relieves venous congestion and oedema
Muscle afferent activity can interfere with pain processing
Which 2 pharmacological therapies are recommended by NICE for management of non-inflammatory back pain?
Oral NSAIDs
Weak opioids with/without paracetamol
Give 3 examples of clothing that a patient with non-inflammatory back pain shouldn’t wear, according to NICE?
Foot orthotics
Belts
Corsets
Does NICE recommend to have nerve stimulation procedures to manage non-inflammatory back pain?
No, patient should not have them
What 3 procedures are recommended by NICE to treat non-inflammatory back pain?
Nerve root/epidural injection
Spinal fusion
Radiofrequency denervation
How are patients managed if they don’t recover from non-inflammatory back pain after 6 weeks, according to NICE?
Biological, psychological, social assessments to check for red flag symptoms
Eg. family relationships, depression and work situation
Give 10 red flags for potential inflammatory back pain?
malignancy
corticosteroid use
systemic unwellness (especially weight loss)
thoracic pain
IV drug use
HIV positive
patient is not within 20-55 age range
violent trauma
widespread neurology
severe restriction of lumbar flexion so patient can’t move back
