Back Pain Flashcards
Red flags for lower back pain
-Age < 20 years or > 50 years
-History of previous malignancy
-Night pain
-History of trauma
-Systemically unwell e.g. weight loss, fever
Causes of lower back pain
-Spinal stenosis
-Ankylosing spondyloarthritis
-Peripheral arterial disease
Overview of spinal stenosis
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
Overview of ankylosing spondyloarthritis
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine
Overview of peripheral arterial disease in back pain
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
Investigation of lower back pain
-Lumbar spine x-ray should not be offered
-MRI
=should only be offered to patients with non-specific back pain ‘only if the result is likely to change management’ and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected
=it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures
Management of lower back pain
-Advice to people with low back pain
=try to encourage self-management
=stay physically active and exercise
-Analgesia
=NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
=proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
=NICE guidelines on neuropathic pain should be followed for patients with sciatica
-Other possible treatments
=exercise programme: ‘Consider a group exercise programme (biomechanical, aerobic, mindbody or a combination of approaches) within the NHS for people ‘
=manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) ‘but only as part of a treatment package including exercise, with or without psychological therapy.’
=radiofrequency denervation
=epidural injections of local anaesthetic and steroid for acute and severe sciatica
Overview of Scheuermann’s disease
Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
Overview of scoliosis
Consists of curvature of the spine in the coronal plane
Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards
Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture
Within structural scoliosis, idiopathic is the most common type
Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine
Overview of spina bifida
Non fusion of the vertebral arches during embryonic development
Three categories; myelomeningocele, spina bifida occulta and meningocele
Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch
The incidence of the condition is reduced by use of folic acid supplements during pregnancy
Overview of spondylolysis
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
May be asymptomatic and affects up to 5% of the population
Spondylolysis is the commonest cause of spondylolisthesis in children
Asymptomatic cases do not require treatment
Overview of spondylolisthesis
This occurs when one vertebra is displaced relative to its immediate inferior vertebral body
May occur as a result of stress fracture or spondylolysis
Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation
