Back Pain Flashcards
1
Q
What is now considered the first-line pharmacological treatment for non-specific lower back pain?
A
NSAIDs
1
Q
What must be co-prescribed with NSAIDs in patients over 45 years old?
A
A proton pump inhibitor (PPI)
2
Q
What is the most useful imaging modality for evaluating soft tissue and neurological structures in back pain?
A
MRI
3
Q
What treatment can be considered for patients with severe and acute sciatica?
A
Epidural injections of local anaesthetic and steroid
4
Q
What interventional procedure may be considered in some patients for pain management?
A
Radiofrequency denervation
5
Q
What is sciatica?
A
Pain caused by compression of one of the five nerve roots contributing to the sciatic nerve, typically felt in the lower back, buttocks, posterior thigh, and lower leg
6
Q
Which nerve roots are most commonly involved in sciatica?
A
L4–S3
MAIN - L4–L5 and L5–S1
7
Q
What is the typical pattern of pain in sciatica?
A
Sharp, shooting or electric pain that radiates down the leg, often following the dermatomal path of the affected nerve root
8
Q
Can sciatica occur without lower back pain?
A
Yes, in some cases leg pain may be present without any back pain
9
Q
What structural abnormality most commonly causes sciatica?
A
Intervertebral disc prolapse, often due to degeneration or injury
10
Q
What are the components of a healthy intervertebral disc?
A
- An outer annulus fibrosus
= collagen fibres - An inner nucleus pulposus
= gel-like core with water content
11
Q
What is piriformis syndrome and how does it relate to sciatica?
A
A condition where the piriformis muscle compresses the sciatic nerve outside the spine, causing sciatica-like symptoms
12
Q
What are two ‘sinister’ causes of sciatica-like symptoms?
A
Spinal tumours and vertebral fractures
13
Q
How does pain from a prolapsed lumbar disc typically present?
A
As dermatomal leg pain that is usually worse than the back pain and aggravated by sitting
14
Q
What is the main symptom that suggests a lumbar disc prolapse over other causes of lower back pain?
A
Leg pain that is more severe than the back pain, typically following a dermatomal distribution
15
Q
What are the features of L3 nerve root compression?
A
- Sensory loss over the anterior thigh
- Weakness in hip flexion
- Weak knee extension and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
16
Q
What are the features of L4 nerve root compression?
A
- Sensory loss over the anterior knee and medial malleolus
- Weak knee extension and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
17
Q
What are the features of L5 nerve root compression?
A
- Sensory loss over the dorsum of the foot
- Weakness in dorsiflexion of the foot and big toe
- Reflexes intact
- Positive sciatic nerve stretch test
18
Q
What are the features of S1 nerve root compression?
A
- Sensory loss over the posterolateral leg and lateral foot
- Weakness in plantar flexion
- Reduced ankle reflex
- Positive sciatic nerve stretch test
19
Q
Which nerve root compression is associated with intact reflexes?
A
L5 nerve root compression
20
Q
What stretch test is positive in L5 or S1 nerve root compression?
A
The sciatic nerve stretch test.
21
Q
What stretch test is typically positive in L3 or L4 nerve root compression?
A
The femoral stretch test
22
Q
What is the first-line treatment for a prolapsed disc according to NICE guidelines?
A
NSAIDs, possibly with a proton pump inhibitor
23
Q
When should MRI be considered for a patient with a suspected prolapsed disc?
A
If symptoms persist beyond 4–6 weeks despite conservative management
24
Should neuropathic analgesia be routinely used for a prolapsed disc without sciatica?
No, first-line treatment remains NSAIDs even without sciatica
25
Cervical Spine Instability occurs where?
Atlanto-axial (C1/2) subluxation - Rheumatoid arthritis
26
A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She describes a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a positive straight leg raise test on the right side but otherwise, the examination is unremarkable. Appropriate analgesia is prescribed
What is the most suitable next step?
physiotherapy, exercises
= sciatica, most likely due to a lumbar disc herniation
27
A 33-year-old woman presents with back pain which radiates down her right leg. This came on suddenly when she was bending down to pick up her child. On examination, straight leg raising is limited to 30 degrees on the right-hand side due to shooting pains down her leg. The sensation is reduced on the dorsum of the right foot, particularly around the big toe and foot dorsiflexion is also weak. The ankle and knee reflexes appear intact.
A diagnosis of disc prolapse is suspected. Which nerve root is most likely to be affected?
L5 lesion features = loss of foot dorsiflexion + sensory loss dorsum of the foot
= L5
28
A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forward or crouching improves the pain.
Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis?
Spinal stenosis
29
What are the key features of spinal stenosis?
(1) Gradual onset of unilateral or bilateral leg pain
(2) Numbness, and weakness that worsens with walking
(3) and is relieved by sitting, leaning forward, or crouching
30
How is spinal stenosis confirmed?
With MRI of the spine
31
How does ankylosing spondylitis typically present?
(1) A young man with chronic lower back pain and stiffness
(2) Worse in the morning and improves with activity
(3) May also have peripheral arthritis
32
What symptoms in ankylosing spondylitis improve with movement?
Morning stiffness and back pain
33
What features suggest peripheral arterial disease in a patient with leg pain?
(1) Pain on walking (claudication) relieved by rest, weak or absent foot pulses and other signs of limb ischaemia. History may include smoking or vascular disease
34
What examination findings is key in diagnosing peripheral arterial disease?
Absent or weak peripheral pulses in the foot or leg
35
You are a doctor in general practice. A 56-year-old man attends a same-day emergency with a new pain in his right leg and foot. The pain has been present for the past 48 hours and is worse at night. He states the pain is in the outer side of his calf and the top of his foot and toes. He has a past medical history of osteoarthritis, gout and hypertension. His regular medications are paracetamol, amlodipine, naproxen, allopurinol and omeprazole.
On examination, he has no ankle or foot tenderness or joint deformity. He has limited movement of the ankle and it is painful to dorsiflex his foot. He has slightly altered sensation over the dorsum of his foot but sensation in the rest of his leg is normal. There is a palpable dorsalis pedis pulse bilaterally.
What is the most likely cause of this man's leg pain?
L5 radiculopathy
36
A 68-year-old avid gardener presents with a 2-week history of lower back pain radiating down his right leg. The patient mentions that he has experienced sensory loss over the anterior aspect of his right thigh and that he has difficulty flexing his right hip, extending his right knee, and adducting his right hip.
On examination, the right knee reflex is diminished. The patient's medical history includes hypertension and osteoarthritis.
What is most likely responsible for the patient's symptoms and why?
L3 nerve root compression
(1) sensory loss over the anterior thigh
(2) weak hip flexion
(3) weak knee extension
(4) weak hip adduction
(5) reduced knee reflex
37
A 67-year-old woman presents to her general practitioner complaining of low mood. She has been living with low-back pain for the last three years and she thinks it's getting worse. Additionally, she just developed some trouble walking as she is unable to lift her right foot properly.
On examination, the right foot dorsiflexion is 2/5 and she has impaired sensation in the whole dorsum. All the reflexes are intact.
What nerve root is most likely affected?
L5
38
A 31-year-old man presents to his GP complaining of loss of sensation in his leg. He is a keen footballer and he has noticed that he is unable to feel the ball on his knee when attempting a kick. Additionally, he feels like his overall performance has decreased recently.
On examination:
Right Left
Hip flexion 5/5 5/5
Hip extension 5/5 5/5
Hip adduction 5/5 3/5
Hip abduction 5/5 5/5
Knee flexion 5/5 5/5
Knee extension 5/5 3/5
Dorsiflexion 5/5 5/5
Plantarflexion 5/5 5/5
There is a loss of sensation over the anterior aspect of the left knee and medial malleolus with reduced patellar reflex.
What nerve root is most likely affected?
L4
39
"A 34-year-old man reports the sudden onset of back pain after bending over to tie his shoelaces. There is tenderness over the lumbar spine on examination and leaning back worsens the pain. Neurological examination and straight leg raising are normal"
What does this suggest?
Facet joint pain
40
How do spinal stenosis, facet joint pain, and vertebral compression fractures differ in terms of presentation and causes?
(1) Spinal stenosis presents with back and/or leg pain, numbness, and weakness that worsens on walking but is relieved by rest, often caused by narrowing of the spinal canal due to degenerative changes or disc herniation.
(2) Facet joint pain is localised back pain over the facet joints, commonly in the cervical and lumbar spine, worsened by extension, and caused by degeneration or trauma.
(3) Vertebral compression fractures cause acute or chronic back pain, typically due to osteoporosis, trauma, or malignancy, and are diagnosed by x-ray
41
"A 76-year-old man reports pain in his buttocks when he walks the dog. The pain comes on after around 500 yards and resolves when he stops. He has a history of chronic obstructive pulmonary disease and ischaemic heart disease. Neurological examination is normal and the foot pulses are difficult to feel in both feet"
What does this suggest
Peripheral arterial disease
42
A 23-year-old man presents to general practice with back pain that has been ongoing for two weeks. This pain is located 'between the shoulder blades' and typically occurs throughout the day. He says that he is fearful that this may be something serious and has been avoiding activity as a result.
What features of this patient's history is a red flag?
Location of pain - thoracic back pain
Other red flags of back pain;
1. age < 20 years or > 50 years
2. history of previous malignancy
3. night pain
4. history of trauma
5. systemically unwell
= weight loss, fever
43
A 55-year-old man attends the GP surgery for lower back pain. He reports that the pain has become gradually worse over the past 5 years. The GP sees him and performs a comprehensive back examination which includes testing for a straight leg raise. The straight leg test is performed by asking the patient to lie down and then the GP raises his leg up, at which point the patient complains of worsening pain in his leg.
Which one of the following pathologies does a positive straight leg raise suggest?
Sciatic nerve pain
44
A 60-year-old cancer survivor presents to the GP with back pain that started after a game of golf last week. The pain is worse when he is lying flat on his back at night; paracetamol has had minimal benefit. He does not experience any bowel or bladder symptoms.
On examination, the back pain is felt most around the thoracic region, but there is no neurologic deficit elicited.
What is the best recommendation for this patient?
Patient has RED FLAGS
= Refer urgently to hospital for further investigation
44
A 44-year-old man is diagnosed with lower back pain. This has been present for around 2 weeks and there are no red flags such as trauma or systemic symptoms. Clinical examination including neurological examination is unremarkable. You encourage him to remain active and give him a 'back sheet' detailing some exercises he could do. He asks for analgesia to 'help him through the day'.
What is the most appropriate initial medication?
Oral NSAIDS
= topical nsaids only recommended for hand/knee pain
45
An S2 lesion would present with what?
1. Sensory loss over the posterior thigh and upper calf
2. Weakness would be predominant in hip extension
46
What is the management for subluxation of the radial head?
Passive supination of the elbow joint whilst flexed to 90 degrees
47
A positive straight raise test indicates what?
Sciatic nerve pain
= positive
48
Suspected cervical spine injury - first thing to do if they're passed out
Jaw thrust
49
What should not be used in patients suspected of cervical spine injury?
Head tilt/ chin lift
50
If NSAIDS are contraindicated, what's the alternative?
Codeine
= eg, Peptic ulcer + HF
51
A 37-year-old woman with a known history of diabetes presents with sudden severe pain in her mid-thoracic region developing over the last 48 hours. She is acutely unwell and is febrile. An urgent blood test reveals a CRP of >200mg/L (normal <5).
She is tender over palpation over her mid-thoracic region. The X-ray is normal but an urgent MRI scan shows destruction of the T6 vertebra and some evidence of infection within the disc
What is the most likely pathology?
Diabetics are particularly susceptible to staphylococcal infections
52
MRI is indicated only in what?
the presence of red flag symptoms, such as neurological deficits, history of malignancy, persistent pain despite conservative treatment, or suspicion of inflammatory or infective causes
53
A 42-year-old woman presents with acute onset back pain. She has previously been diagnosed with breast cancer and has completed two cycles of chemotherapy.
She is complaining of pain radiating down both legs as well as numbness and tingling in her legs. On examination, she has a positive straight leg raise test with reduced knee and ankle reflexes. There is reduced sensation in the L4 dermatomal pattern
Where does the lesion localise to?
Lumbar nerve root
54
A 40-year-old gentleman presents to the GP with pain in his back. He lifted a heavy box two weeks ago and felt his back giving way
He has been suffering from lower back pain ever since. The pain is on the left side of his lower back and he occasionally experiences numbness and tingling in his foot
On examination, the gait is normal and there is no tenderness over the lower back. There is reduced spinal flexion due to pain. On performing the straight leg raise, the patient complains of back pain. There are no other symptoms, his observations are stable and there is no other medical history
What is the most likely diagnosis?
Lumbar disc herniation
55
Straight leg raise is usually what in spinal stenosis?
Negative
56
A 45-year-old has sudden severe lower back pain which started whilst helping
a friend move house. The pain is worse when coughing. They are otherwise well.
What is the most likely cause of this presentation?
Acute disc tear
57
A patient presents with difficulty in extending the toes and foot drop. Which nerve root is likely involved?
L5
58
Which nerve root is most commonly involved in a herniated disc at the L3-L4 level?
L4
59
A person experiences weakness in knee extension and patellar reflex loss. Which nerve root is implicated?
L4
60
A patient has numbness on the lateral side of the thigh, and their hip flexion is weak. Which nerve is affected?
L3
