BACK PAIN

Question 1

Yellow flags associated with back pain

Answer 1

Pessimistic attitude toward pain, excessive fear of movement and activity and little hope for improvement
Work-related problems (e.g. dissatisfaction, conflicts)
Emotional problems (e.g. depression, anxiety, worry)
Generalized pain (e.g. headache, fatigue, dizziness)
Desire for passive treatment, little ability to be proactive
Previous episodes of low back pain that were followed for an extended period
of time

Question 2

Red flags associated with back pain

Answer 2

Patients < 20 years or > 55 years of age experiencing back pain for the first time
Patients experiencing pain significantly different from previous episodes
Pain that is constant over time and does not disappear during sleep
General malaise and poor general condition
Traumatic injuries, tumours, steroid use or improper use of immunosuppressants
Neurological compromise
Spinal deformity
Pronounced morning stiffness lasting for longer than 1 hour and/or high ESR

Question 3

Symptoms of neuropathic pain

Answer 3

Pricking, tingling, pins and needles
Electric shocks of shooting
Hot or burning
Numbness
Altered sensation
Radicular pain
Incontinence of urine and

Question 4

Causes of back pain

Answer 4

Mechanical (e.g. disc degeneration, fractured vertebrae, instability)
Neurogenic (e.g., herniated disc, spinal stenosis, osteophyte damage to nerve root)
Non-mechanical spinal conditions (e.g., neoplasm, infections, inflammatory arthritis, Paget’s disease)
Referred visceral pain (e.g., GIT disease, kidney disease, abdominal aortic aneurism)
Other

Question 5

Signs of back pain

Answer 5

Deformity of spine
Tenderness in affected region
Weakness of the affected limb
Muscle wasting in the affected limb
Altered sensation in the affected limb

Question 6

According to ACR, imaging is usually not appropriate for this presentation of back pain

Answer 6

Uncomplicated, acute low back pain

Question 7

According to ACR, MRI of lumbar spine without contrast usually appropriate for back pain in the presence of …….

Answer 7

Low-velocity trauma, osteoporosis or age >
70 years
Low back pain and/or radiculopathy in
surgical or interventional candidate

Question 8

Investigations for back pain

Answer 8

BC
ESR
Mantoux
Chest X-ray if TB suspected
Rheumatoid factor
HLA-B27 (if inflammatory arthritides is suspected)
CT scan of spine
CT myelogram
Plain X-rays of spine

Question 8

According to ACR, MRI of lumbar spine with and without contrast usually appropriate for back pain in the presence of …….

Answer 8

Suspicion of cancer, infection or
immunosuppression
Prior lumbar surgery
Cauda equina syndrome

Question 9

Treatment objectives in back pain

Answer 9

Pain relief
Prevention of recurrence
Identification of red and yellow flags
Treatment of underlying cause
Improvement of function

Question 10

Non-pharmacological interventions in back pain

Answer 10

Splints
Physiotherapy
Weight loss and lifestyle adjustment
Acupuncture
Sleep hygiene
Occupational therapy

Question 11

First line Pharmacological treatment for relief of acute pain

Answer 11

Tab Paracetamol or PO Celecoxib or PO Diclofenac or PO Ibuprofen
and
PO Diazepam or PO Methocabarmol or PO Tizanidine

Question 12

Second line management of acute back pain

Answer 12

Tab Amitriptyline 25-50mg daily or Tab Pregabalin

and

Tramadol or Codeine or Morphine