Back pain Flashcards
RF for non-specific back pain
obesity
physical inactivity
occupational factors
depression
psychological conditions
Causes of back pain in 15-30s
prolapsed disc
trauma
fractures
ankylosing spondylitis
spondylolithesis (forward shift of one vertebrae over another which is congenital or due to trauma)
pregnancy
causes of back pain 30-50
degenerative spinal disease
prolapsed disc
malignancy
Causes of back pain >50
degenerative spinal disease
osteoporotic vertebral collapse
Paget’s disease
malignancy
myeloma
spinal stenosis
Mx for non-specific back pain
exclude any underlying causes
1st line = NSAIDs (ibruprofen and naproxen) at lowest effective dose for shortest time + PPI
- Don’t offer paracetamol alone, opioids, SSRIs/SNRIs/TCAs
Adjuncts: BDZs (diazepam) for muscle spasms
Advise follow up if doesn’t improve 3-4w
Assess for poor outcome
Self-management advice
Management for back pain in higher risk for poorer outcomes
refer to group exercise programme
refer to PT for manual therapy
refer to CBT as part of package with exercise and manual therapy
promote and facilitate return to work or normal ADLs
Self management advice for non-specific back pain
acute non-specific lower back pain is not caused by serious structural damage
most people can reasonably be expected to recover from an episode of non-specific back pain within a period of weeks
simple exercises (e.g better backs provided by Backcare charity)
encourage patient to stay active, resume normal activities and return to work as soon as possible
Red flags for back pain
aged <20 or >55
acute onset in elderly pain
constant or progressive pain
nocturnal pain
worse pain on being supine
fever, night sweats, weight loss
hx of malignancy
abdo mass
thoracic back pain
morning stiffness
bilateral or alternating leg pain
neuro disturbance (incl. sciatica)
sphincter disturbance
current or recent infection
immunosuppression (e.g steroids/HIV)
leg claudication or exercise-related leg weakness/numbness (spinal stenosis)
What do yellow flags for back pain mean?
psychosocial indicators suggesting an increased risk of progression of back pain to cause long-term distress, disability and pain
What is the STarT screening tool for back pain?
assess for poor prognostic indicators
score of 3 or less = low risk
score of 4 or more = high risk
List some examples of yellow flags
attitudes and belief
- pain is harmful or severely disabling
- expectation that passive treatment rather than active participation will help
- feeling that “nobody believes pain is real” may relate to previous encounters with HCPs
fear-avoidance behaviours (avoiding activity due to fear of pain)
low mood and social withdrawal
poor family relationships or hx of abusive relationship
financial concerns particularly related to ill health or ongoing pain
work related factors (e.g conflict over sick leave, inability to perform current job tasks)
L2: pain, weakness and reflex attached
pain - across upper thigh
weakness - hip flexion and adduction
reflex - none
L3: pain, weakness, reflex
pain - across lower thigh
weakness - hip adduction, knee extension
reflex - knee jerk
L4: pain, weakness, reflex
pain - across knee to medial malleolus
weakness - knee extension, foot inversion and dorsiflexon
reflex - knee jerk
L5: pain, weakness, reflex affected
pain - lateral shin to dorsum of foot and great toe
weakness - hip extension and abduction, knee flexion, foot and great toe dorsiflexion
reflex - great toe jerk
S1: pain, weakness, refle
pain - posterior calf to lateral foot and little toe
weakness - knee flexion, foot and toe plantar flexion, foot eversion
reflex - ankle jerk
Where does spinal cord terminate
L2/L3
cauda equina below this
Causes of CES
herniated disc (most common)
tumours, particularly metastasis
spondylolithesis (anterior displacement of a vertebra out of line with below)
abscess (infection)
trauma
Sx of CES
saddle anaesthesia
loss of sensation in bladder and rectum (not knowing when they are full)
urinary retention or incontinence
faecal incontinence
bilateral sciatica
bilateral or severe motor weakness in legs
reduced anal tone on PR exam
Mx of CES
neurosurgical emergency
immediate hospital admission
emergency MRI scan to confirm or exclude CES
neurosurgical input to consider lumbar decompression surgery
Metastatic spinal cord compression: what is, presentation
Oncological emergency
metastatic lesion compresses spinal cord (before start of cauda equina)
presents with back pain (worse on coughing or straining), motor and sensory signs
Mx of metastatic spinal cord compresssion
high dose dexamethasone (reduced swelling in tumour and relieve compression)
analgesia
surgery
RTx
CTx
Types of spinal stenosis
central stenosis - narrowing of central spinal cord
lateral stenosis - narrowing of nerve root canals
foramina stenosis - narrowing of intervertebral foramina
Causes of spinal stenosis
congenital spinal stenosis
degenerative changes
herniated discs
thickening of ligamenta flava or posterior longitudinal ligament
spinal fractures
spondylolisthesis (anterior displacement of vertebra out of line with one below)
tumours
Presentation for spinal stenosis
gradual onset
depends on degree of narrowing and spinal cord
severe can present with CES
intermittent neurogenic claudication - lower back pain, buttock and leg pain, leg weakness
bending forward (flexing spine) expands spinal canal and improves sx
standing straight (extending spine) narrows canal and worsens sx
lateral stenosis and foramina stenosis - lumbar spine causes sx of sciatica
Investigations for spinal stenosis
MRI
exclude peripheral arterial disease (ABPI and CT angio) when intermittent claudication are present
Mx for spinal stenosis
exercise and weight loss
analgesia
PT
decompression surgery where conservative surgery fails
laminectomy refers to removal of part or all of lamina from affected vertebra
epidural injections with local anaesthetic are unclear and not generally used
Causes of mechanical back pain
muscle or ligament strain
facet joint dysfunction
sacroiliac joint dysfunction
herniated disc
spondylolithesis (anterior displacement of a vertebra out of line with one below)
scoliosis
degenerative changes
Causes of neck pain
muscle or ligament strain
torticollis (waking up with unilaterally stiff and painful neck due to muscle spasm)
whiplash
cervical spondylosis
red flag causes of back pain
spinal fracture
CES
spinal stenosis
ankylosing spondylitis
spinal infection
What cancers commonly metastasise to bone?
prostate
renal
thyroid
breast
lung
Mx of sciatica
Amitriptyline
duloxetine
Specialist Mx:
- epidural corticosteroids injections
- local anaesthetic injections
- radiofrequency denervation
- spinal decompression
