Back Pain Flashcards
Incidence and impact of Back pain
80% lifetime incidence – 75% of pts improve within 4wks, 95% within 6wks BUT 70% recurrence - 1.6million chronic sufferers
2nd most common illness after the cold – biggest reason people see GPs and costs £12.3bn/yr
Causes of low back pain
95% – mechanical low back pain
4% – Nerve root pain
1% – Serious spine pathology
Yellow flags versus Red flags
Red flags are signs of serious sinister pathology
Yellow flags are psycho-social predictors of poor outcome (A,B,C,D,E,F,W)
Yellow flags for low back pain
Attitudes & beliefs about back pain
Behaviours, Compensation issues, Diagnosis and treatment issues, Emotions, Family and Work
Red flags for low back pain (5,4,7)
Types of pain: constant or Progressive, nocturnal, thoracic, bony tenderness, insidious onset,
Associated symptoms: weight loss, fever, night sweats, persistent severe restriction of lumbar flexion
History: Trauma, Hx of Ca, Steroid use, IV drug use, HIV or immunosuppression, Structural deformity, age 50yrs,
Unhelpful beliefs (2) or behaviours (2) about low back pain
The belief that pain is harmful or severely disabling
Expectation that passive treatment not active participation will help
Fear/avoidance behaviour
Low mood and social withdrawal
Serious spinal pathology which causes back pain (6)
Trauma or fractures Infection (TB, etc) Malignancy (primary or secondary) Cauda equina Inflammatory Visceral (referred)
Detecting serious spinal causes when asking about back pain
Always search for red flags – patient may not volunteer them – may not have thought to comment on weight loss etc
Causes of Nerve Root pain
Herniated discs - 90% - (protrusion, extrusion or sequestration)
Canal or foraminal stenosis - can effect the exiting or ‘traversing’ nerve root (one vertebrae below)
Spondylolithesis
Disc Protrusion
Focal or symmetric protrusion of the nucleus pulposis beyond the end-plate but the annulus is still intact
Disc Extrusion
Disc/nucleus extends beyond the confines of the annulus
Disc Sequestration
Fragmentation of the disc where there is no continuity with the original disc
Presentation of Herniated discs
Unilateral (can be bilateral) - leg pain>back pain –> dermatomal pattern – may also have paraesthesia or changes in power, sensation or reflexes (single nerve root)
Lumbar flexion is restricted
Nerve irritation/radiculopathy signs
Nerve irritation/radiculopathy signs
Limitation of the straight leg raise with reproduction of leg pain (not back pain) – coughing/sneezing worsens pain
pain may be sharp or shooting
Crossed straight leg raise – if lifting the unaffected leg causes pain in the affected leg this is very specific for sciatic radiculopathy
Nerve roots most commonly affected by herniated discs
L4-5 and L5-S1 – this will effect L4, L5 and S1 (the sciatic nerve)
L2 nerve Root
Dermatome – Groin
Myotome – Hip flexors and adductors
Reflex – none
L3 nerve Root
Dermatome – Lateral/anterior thigh
Myotome – Quads (hip addiction, knee extension)
Reflex – Knee jerk
L4 nerve Root
Dermatome – Medial lower leg to med malleolus
Myotome – dorsiflexion of the ankle/foot, foot inversion
Reflex – Knee jerk
L5 nerve Root
Dermatome – Dorsum of the foot and big toe
Myotome – Foot eversion & extensor hallus longus
Reflex – none
S1 nerve Root
Dermatome – Lateral border of the foot and sole
Myotome – Knee flexion, plantar flexion of the foot, foot eversion
Reflex – Ankle jerk
Treatment of nerve root pain
90% will improve with 6 weeks – educate, reassure and advise – 95% resolve within 12wks – After 12wks consider physiotherapy, medication or surgery/injections (if getting worse) -only after MRI
Interventions for worsening nerve root pain
Injections – nerve root block for back pain & epidural for back and leg pain – evidence is conflicting
Surgery – Microdiscectomy, discectomy or fusion of vertebrae – little significant evidence supporting surgery over non-operative management
Criteria for nerve root surgery
Radiculopathy and severe pain unrelieved by conservative management lasting >6wks with progressive neurological deficit – must be imaging showing disc herniation with correlates with examination findings
Spondylolithesis - what is it, how can it be graded and what types are there?
Anterior displacement of the vertebrae or vertebral column in relation to the vertebrae below – most commonly L5 on S1
Can be graded Meyerding or Wiltse
Can be traumatic, Isthmic or Degenerative
Posterior displacement is retrolithesis
Grading Spondylolithesis - Meyerding
Based on percentage anterior slippage:
Grade 1 – up to 25%, Grade 2 – 25-50%,
Grade 3 – 50-75%, Grade 4 – 76-100%,
Grade 5 – Below the anterior border of the lower vertebrae
Grading Spondylolithesis - Wiltse
Based on cause:
Type 1 – Dysplastic, Type 2 – Isthmic,
Type 3 – Degerative, Type 4 – Traumatic,
Type 5 – Pathological, Type 6 – Post-surgical
Did I do that pathological person?
Isthmic spondylolisthesis (Wiltse type 2)
Developmental – most common form (~5% of pop) but cause unknown
Lesion of per interarticularitis of L4 or L5 - can be unilateral or bilateral
Due to abnormal development of the neural arch or a genetically induced weakness
Common presentations of Isthmic spondylolisthesis
Adolescents/young adults as due to fatigue fracture (repetitive stress) rather than acute trauma –> weightlifting, gymnastics, football etc
Usually occurs 6-16yrs but may present years later
Signs of Isthmic spondylolisthesis
Gradual onset of general low back ache with repetitive movements, morning stiffness and night pain after activity
May have unilateral lumbar, buttock or leg pain if nervous entrapment
Aggravated by prolonged standing, walking or running
Degenerative spondylolisthesis (Wiltse type 3)
5-6x more common in women – not associated with a pars defect – result of facet joint degeneration (possibly spinal structure or hormonal ligament weakness)
Most common at L4/5
Presentations of degenerative spondylolisthesis
Mild, activity related back pain with a loss of spinal mobility – pain associated with sustained extension loading (walking, standing)
Symptoms may present as if stenosis or radiculopathy
Treatment of spondylolisthesis or spinal stenosis
Most pts treated conservatively (education, physiotherapy) and with standard analgesia
Surgery if leg pain is persistent or if there is progressive focal neurology
Dysplastic spondylolisthesis (Wiltse type 1)
a rare congenital spondylolisthesis due to a malformation of the lumbosacral junction resulting in small, incompetent facet joints
Pathological spondylolisthesis (Wiltse type 5)
a rare form associated with damage to the posterior elements of the vertebrae from diseases including: Paget’s disease of bone, tuberculosis, giant-cell tumors, metastases, etc
Spinal stenosis
Narrowing of the spinal canal – can be Central (thickened ligamentum flavum), Lateral recess or foraminal (osteophyte formation or ankylosis). Should have an MRI to confirm.
Signs of spinal stenosis
Low back pain (first sign) & bi/unilateral leg pain – worsened by extension or walking, improved by increasing canal diameter (flexion, squatting, sitting)
SLR may be normal – major signs are lower limb numbness, pain or weakness
Modic changes
Pathological changes in vertebral body and end-plate seen on MRI – common cause of LBP which is often constant day and night
May be related to degenerative disc changes
Types of Modic changes
Type I – Endplate disruption/fissuring with vascular granulation tissue - commonly have LBP
Type II – Endplate disruption, reactive bone formation and vascular granulation with infiltration of fat in adjacent haemopoetic bone
Type III – Advanced Endplate bony sclerosis
Classical presentation of mechanical low back pain
age 20-55 well patient – often develops spontaneously
Pain is in the lumbosacral back, buttocks and thighs (not below knee) – varies with activity – in most cases due to muscle or joint strain but can be underlying pathology
Treatment for acute low back pain
Reassure and advise to continue normal activity – prescribe analgesia (paracetamol/NSAIDs) – consider adding a short course of muscle relaxants if not improving
X-rays in back pain
No indications if non-specific low back pain
Can be used if suspected fracture or serious pathology, to confirm structural basis of symptoms and in prep for surgery
NB bone destruction only shows at 30-50% so be beware of false negatives
Indications for MRI in back pain
Only if suspecting serious pathology or worsening (multilevel) neurology
If there is >6wks debilitating leg pain or In prep for surgery
NOT as a screening tool - 20-70% of people have asymptomatic disc herniations
Management of persistent LBP (>6wks)
Investigate for psychosocial factors/yellow flags
Refer for spinal manipulation (physiotherapy etc) if not returning to normal activity – offer exercise classes
Exclude serious pathology or red flags
Differences between chronic and acute back pain (4,3)
Acute –>Useful as indicates tissue injury, self limiting and associated with stress response, treat nociceptive cause
Chronic –>Not useful as due to physiological dysfunction associated with depression/psychosocial issues. No recognisable end point
Patterns of back pain (6)
Axial back pain
Radicular pattern
Facet or SI joint tenderness
Consider impact of posture (muscle activation), activity and neurological involvement
Causes of lumbar back pain with an axial distribution (3)
Facet joint – 10-30%
Discogenic – 50%
Sacroiliac – 10-15%
Neuropathic pain in back pain (5)
Significant in 50% of cases – Increasingly common with increasing severity – central sensitisation is a common feature
Can be treated with spinal cord stimulator (if proved to be treatment refractory eg failed back pain syndrome)
Or by a pain management programme
Medication of back pain
Analgesics – Paracetamol, NSAIDs, Opioids/tramadol
Adjuvants – antidepressants (Nortriptyline) or anticonvulsants (Gabapentin, pregabalin)
Concerns about side effects/tolerance with chronic use
Intra-articular injections
Used in facet & sacroiliac joint disease
Can be diagnostic (clarify facet or SI cause) and simulates the results of permanent treatments (spinal fusion or denervation)
Therapeutic –> reduce inflammation & pain, helps to increase mobility and allow rehabilitation
Clinical signs of facet joint pain
Localised unilateral or bilateral low back pain without radiation – significant paravertebral tenderness. Can be sudden or chronic onset
Aggravated with ipsilateral pressure, movements (extension particularly, lateral flexion or rotation)
Positive response to local block or intra-articular injection
Causes of facet joint pain
Most commonly arthritic degeneration or inflammation of the joint
Facet joint pain is more commonly cervical rather than lumbar
Treatment of Facet joint pain
Can be treated conservatively (exercise, physiotherapy & analgesia) or using intra-articular injections
RF-facet joint denervation can also be used – successful if used in correct patients (actually have facet joint disease)
Pain management programme
CBT and physical therapy Aims to decrease the distress and disability associated with chronic pain - not to reduce pain Effective and cost effective With NSAIDs + paracetamol + codeine May trial amitriptyline
Signs of inflammatory back pain (Ankylosing spondylitis etc)
Gradual onset before 40yrs (26-30), - 1% prevalence
Morning stiffness and pain which are relieved by exercise
Family history
Iritis, rashes, colitis
Raised ESR/CRP
Cauda Equina syndrome (5)
Bladder rention (usually) and anal sphincter disturbance
Saddle anaesthesia
Lower limb weakness leading to gait disturbance
Requires urgent referral and treatment
Axial loading
Push on the head to apply additonal pressure on the spine – reproduction of symptoms suggests Disc herniation or canal stenosis
Causes of inflammatory back pain (4)
Ankylosing spondylitis
Psoriatic or enteropathic spondyloarthritis
Non-radiographic axial spondyloarthritis (mostly female)
Investigations for red flag symptoms in back pain
FBC, CRP, ESR (myeloma, infection, tumour).
U&E, ALP (Paget’s, myeloma).
PSA
Imaging: MRI for disc prolapse, cord compression, cancer, infection, inflammation
