Back pain

Question 1

What is the usual pathology causing mechanical back pain?

Answer 1

Soft tissue injury → dysfunction of whole spine → muscle spasm → pain.
Usually a specific incident that caused injury

Question 2

How can you manage simple mechanical back pain?

Answer 2

Conservative - patient education in lifting techniques, keep active. Physiotherapy, psychosocial issues, encourage swimming - exercise and warmth
Medical - Paracetamol +/- NSAIDs +/- Codeine, low dose Diazepam for temporary muscle relaxation

Question 3

Define disc prolapse

Answer 3

Herniation of nucleus pulposus through annulus fibrosus

Question 4

Which nerve roots are most commonly effected by disc prolapse?

Answer 4

L5/S1 by prolapse of L4/L5, L5/S1 discs

Question 5

How can disc prolapse present?

Answer 5

Severe pain on sneezing, coughing or twisting a few days post back strain
Lower back pain
Sciatica

Question 6

What is Sciatica?

Answer 6

Shooting radicular pain down leg to foot
Can have numbness and tingling
Nerve roots L4-S3
Can do straight leg raise test with dorsiflexion of foot to stretch the sciatic nerve - pain will increase if impingement higher up

Question 7

What are some of the signs of disc prolapse?

Answer 7

Limited spinal flexion and extension
Free lateral flexion
Pain on straight leg raise
Radiculopathy if lateral herniation
Corda Equina syndrome if central herniation

Question 8

What signs would you get with a L4/L5 disc prolapse?

Answer 8

L5 root compression
Decreased sensation over lateral lower leg and dorsum of foot
Weak hallux extension +/- foot drop
Weakened inversion can distinguish from Common fibular nerve palsy

Question 9

How does Common fibular nerve palsy present?

Answer 9

Foot drop

Decreased sensation over lateral lower leg and dorsum of foot

Question 10

What signs would you get with a L5/S1 disc prolapse?

Answer 10

S1 root compression
Weakened plantarflexion and eversion
Loss of ankle jerk reflex
Calf pain
Decreased sensation on sole of foot and back of calf

Question 11

What investigations can be done in a suspected disc prolapse?

Answer 11

MRI

Question 12

What are the management options for a disc prolapse?

Answer 12

Conservative - Short period of rest followed by physio
Medical - Analgesia, Steroid injections
Surgical - Laminectomy or Disectomy - needed if muscle weakness, severe pain or Cauda Equina syndrome

Question 13

What is Spondylolisthesis?

Answer 13

Displacement of one lumbar vertebrae onto another
Usually anteriorly
Usually L5 on S1

Question 14

What are some of the causes of Spondylolisthesis?

Answer 14

Congenital malformation
Spondylosis
Osteoarthritis

Question 15

How does Spondylolisthesis usually present?

Answer 15

Pain worse on standing
May have hamstring tightness, sciatica, abnormal gait
Diagnose with X ray

Question 16

How can you treat Spondylolisthesis?

Answer 16

Corset
Nerve release
Spinal fusion

Question 17

What is Spinal Stenosis?

Answer 17

Developmental predisposition ± facet joint osteoarthritis

→ generalized narrowing of lumbar spinal canal.

Question 18

How does Spinal Stenosis usually present?

Answer 18

Spinal claudication (Aching or heavy buttock and lower limb pain on walking)
Rapid onset
May have paraesthesiae/numbness
Pain eased by leaning forward (Increasing space in canal)
Pain worse on spine extension

Question 19

What investigations can be done in a patient with suspected Spinal Stenosis?

Answer 19

MRI

Question 20

What is the management of Spinal Stenosis?

Answer 20

Corset
NSAIDs
Epidural spinal injection
Canal decompression surgery