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Back Pain Flashcards

1
Q

Incidence and impact of Back pain

A

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

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2
Q

Causes of low back pain

A

95% – mechanical low back pain
4% – Nerve root pain
1% – Serious spine pathology

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3
Q

Yellow flags versus Red flags

A

Red flags are signs of serious sinister pathology

Yellow flags are psycho-social predictors of poor outcome (A,B,C,D,E,F,W)

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4
Q

Yellow flags for low back pain

A

Attitudes & beliefs about back pain

Behaviours, Compensation issues, Diagnosis and treatment issues, Emotions, Family and Work

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5
Q

Red flags for low back pain (5,4,7)

A

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,

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6
Q

Unhelpful beliefs (2) or behaviours (2) about low back pain

A

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

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7
Q

Serious spinal pathology which causes back pain (6)

A 
Trauma or fractures
Infection (TB, etc)
Malignancy (primary or secondary)
Cauda equina
Inflammatory
Visceral (referred)
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8
Q

Detecting serious spinal causes when asking about back pain

A

Always search for red flags – patient may not volunteer them – may not have thought to comment on weight loss etc

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9
Q

Causes of Nerve Root pain

A

Herniated discs - 90% - (protrusion, extrusion or sequestration)
Canal or foraminal stenosis - can effect the exiting or ‘traversing’ nerve root (one vertebrae below)
Spondylolithesis

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10
Q

Disc Protrusion

A

Focal or symmetric protrusion of the nucleus pulposis beyond the end-plate but the annulus is still intact

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11
Q

Disc Extrusion

A

Disc/nucleus extends beyond the confines of the annulus

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12
Q

Disc Sequestration

A

Fragmentation of the disc where there is no continuity with the original disc

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13
Q

Presentation of Herniated discs

A

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

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14
Q

Nerve irritation/radiculopathy signs

A

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

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15
Q

Nerve roots most commonly affected by herniated discs

A

L4-5 and L5-S1 – this will effect L4, L5 and S1 (the sciatic nerve)

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16
Q

L2 nerve Root

A

Dermatome – Groin
Myotome – Hip flexors and adductors
Reflex – none

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17
Q

L3 nerve Root

A

Dermatome – Lateral/anterior thigh
Myotome – Quads (hip addiction, knee extension)
Reflex – Knee jerk

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18
Q

L4 nerve Root

A

Dermatome – Medial lower leg to med malleolus
Myotome – dorsiflexion of the ankle/foot, foot inversion
Reflex – Knee jerk

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19
Q

L5 nerve Root

A

Dermatome – Dorsum of the foot and big toe
Myotome – Foot eversion & extensor hallus longus
Reflex – none

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20
Q

S1 nerve Root

A

Dermatome – Lateral border of the foot and sole
Myotome – Knee flexion, plantar flexion of the foot, foot eversion
Reflex – Ankle jerk

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21
Q

Treatment of nerve root pain

A

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

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22
Q

Interventions for worsening nerve root pain

A

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

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23
Q

Criteria for nerve root surgery

A

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

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24
Q

Spondylolithesis - what is it, how can it be graded and what types are there?

A

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

25
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
26
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?
27
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
28
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
29
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
30
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
31
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
32
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
33
Dysplastic spondylolisthesis (Wiltse type 1)
a rare congenital spondylolisthesis due to a malformation of the lumbosacral junction resulting in small, incompetent facet joints
34
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
35
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.
36
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
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
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
45
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
46
Causes of lumbar back pain with an axial distribution (3)
Facet joint -- 10-30% Discogenic -- 50% Sacroiliac -- 10-15%
47
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
48
Medication of back pain
Analgesics -- Paracetamol, NSAIDs, Opioids/tramadol Adjuvants -- antidepressants (Nortriptyline) or anticonvulsants (Gabapentin, pregabalin) Concerns about side effects/tolerance with chronic use
49
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
50
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
51
Causes of facet joint pain
Most commonly arthritic degeneration or inflammation of the joint Facet joint pain is more commonly cervical rather than lumbar
52
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)
53
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 ```
54
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
55
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
56
Axial loading
Push on the head to apply additonal pressure on the spine -- reproduction of symptoms suggests Disc herniation or canal stenosis
57
Causes of inflammatory back pain (4)
Ankylosing spondylitis Psoriatic or enteropathic spondyloarthritis Non-radiographic axial spondyloarthritis (mostly female)
58
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

Rheumatology (15 decks)

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