Back pain Flashcards
Differential diagnosis for back pain: mechanical, systemic, referred
1) Mechanical Lumbar muscular strain/sprain Herniated nucleus pulposus (HNP) Spinal stenosis Compression fracture Degenerative disc disease or facet arthropathy Spondylolysis and/or spondylolisthesis
2) Systemic Vertebral discitis/osteomyelitis Malignancy Inflammatory spondyloarthropathy Connective tissue disease
3) Referred Aortic abdominal aneurysm Pancreatitis Pyelonephritis Renal colic Peptic ulcer disease
Red flag conditions
Herniated nucleus pulposus (HNP) Vertebral discitis/osteomyelitis/epidural abscess Malignancy Aortic abdominal aneurysm Cauda equina
Red flag features for sinister cause
Aged 55 years Acute onset in elderly Constant/progressive Nocturnal Worse on being supine Fever, night sweats, weight loss History of malignancy Abdominal mass Thoracic back pain Morning stiffness Bilateral/alternating leg pain Neurological disturbance Sphincter Current/recent infection Immunosuppression Leg claudication
Risk factors for chronicity
Have you had time off work in the past with back pain?
What do you understand is the cause of your back pain?
What are you expecting will help?
How are your employer, coworkers, family responding to your back pain?
What are you doing to cope with back pain?
Do you think that you will return to work? When?
Yellow flags
Belief back pain in harmful/ catasrophising Fear-avoidance/reduced activity Tendency to low mood and withdrawal from social interaction Expectation of passive interventions rather than a beleif that active participation will help
Examination
Gait Range of motion Localised tenderness A positive straight-leg raise or contralateral straight-leg raise Neurological examination Rectal tone Vascular
Investigations- blood
Not usually required
If suggestions of infection, malignancy: FBC, ESR, C-reactive protein (CRP), and blood cultures
Urinalysis if suspect pyelonephritis
Lumbar Xray
Lumbar X-ray rarely helpful--> unless diagnsoisng AS, will show OA changes, disc narrowing--> not recommended in acute/without red flags Consider after 6-8 weeks ?PSA-->prostatic Ca ESR/CRP-->inflammatory FBC-->anemia ALP+-->MM, osteomalacia, pagets, metastasis
Imaging if red flags
If red flags-->MRI, CT if contrindicated(pacemaker, metal clips) MRI: 64% of normal (asymptomatic) people have abnormalities in MRI
Management of mechanical
Advice to stay active, education and reasurance (90% recover in 6 weeks, however recurrences are common 50% w/ intermittent), avoid work disability
?Physical therapy
?Psychologist
1g paracetamol 4-6 hourly,
max 4g
+/-
300mg ibuprofen 4X daily
How long to try NSAIDs, if not working
If pain persists consider
exacerbating factors.
Goal is not to be pain free,
but to be manageable
codeine 30 to 60 mg orally,
6-hourly as necessary
Lower limb neurological movements- spinal level
hip flexion • L2, L3, L4 hip adduction • L2, L3, L4 hip abduction • L2, L3, L4 hip extension • S1 knee extension • L2, L3, L4 knee flexion • L4, L5, S1, S2 foot dorsiflexion (walk on heels) • L4, L5 foot plantarflexion (walk on toes) • S1
Grading muscle strength
o grading of muscle strength
• 0 – no muscle contraction detected
• 1 – flicker or trace contraction
• 2 – active movement with gravity eliminated
• 3 – active movement against gravity
• 4 – active movement against gravity and some resistance
• 5 – active movement against full resistance without evident fatigue (normal)
Describe the slump test
Slump test
• Seat patient with legs hanging off bed
• Slump patient forward at thoracolumbar spine
• If this position does not cause pain, ask patient to flex neck, then extend one knee as much as possible
• If pain is felt, return neck to normal position; if the patient is still unable to extend knee due to pain, the test is POSITIVE
• If extending the knee does not cause pain, ask patient to actively dorsiflex ankle; if dorsiflexion causes pain, ask patient to slightly flex the knee while still dorsiflexing; if pain is reproduced, test is positive
• Perform bilaterally
• Positive test indicates likely lumbar disc herniation
What is radicular pain
Radicular pain, caused by nerve root compression from a disc protrusion (most common cause) or tumour or a narrowed intervertebral foramina, typically produces pain in the leg related to the dermatome and myotome innervated by that nerve root. Leg pain may occur alone without back pain and vary considerably in intensity.
