Back Pain

Question 1

Red flags of back pain - demographics and history of patient

Answer 1

<20; >55
Acute onset if elderly
Hx malignancy
Immunosuppression (infection)
Drug abuse or HIV +ve (infection)

Question 2

Red flags of back pain - features of the pain

Answer 2

Thoracic back pain
Violent trauma (vertebral fracture)
Spine movement in all directions painful
Unrelated to mechanical events
Local bony tenderness

Question 3

Back pain red flags - timing, frequency + exacerbation

Answer 3

Constant or progressive
Night/rest pain (malignancy, infection, AAA)
Worse if supine

Question 4

Back pain red flags - associated symptoms/signs

Answer 4

Fever, night sweats, systemically unwell (infection eg osteomyelitis of spine)
Weight loss (cancer)
Abdo mass (AAA, cancer)
Bilateral/alternating leg pain
Neuro disturbance (incl sciatica)
Leg claudication or exercise-related leg weakness/numbness
Sphincter disturbance
Morning stiffness
Current/recent infection
Raised ESR
CNS deficit at more than 1 root level

Question 5

Causes of back pain age 15-30

Answer 5

Prolapsed disc
Trauma
Fractures
Ank spond
Pregnancy

Question 6

Causes of back pain age 30-50

Answer 6

Degenerative spinal disease
Prolapsed disc
Malignancy - primary or secondary

Question 7

Causes of back pain > 50

Answer 7

Degenerative
Osteoporotic vertebral collapse
Paget’s
Malignancy
Myeloma
Spinal stenosis

Question 8

Investigations to rule out myeloma, infection, tumour

Answer 8

FBC
ESR
CRP
Serum/urine electrophoresis - myeloma
PSA - prostate cancer mets

Question 9

Imaging in lower back pain

Answer 9

MRI - disc prolapse, cord compression, cancer, infection, inflammation eg sacroiliitis
X-rays not indicated

Question 10

Red flags for lower back pain

Answer 10

Malignancy hx
Age <20 or >50
Night pain
Trauma hx
Systemically unwell - weight loss, fever
Cauda equina - anaesthesia, bladder/bowel, paralysis of legs?

MANTS

Question 11

Spinal stenosis - presentation + investigations

Answer 11

Gradual onset
Uni/bilateral leg symptoms: pain, numbness, weakness +- back pain (pain aching/crawling)
Worse on walking; relieved by sitting, leaning forward, crouching
Exam often normal, MRI confirms

Question 12

Investigations - lower back pain

Answer 12

MRI - only if suspecting malignancy, infection, fracture, cauda equina, ank spond (or if result likely to change mgmt)
Don’t offer lumbar xray

Question 13

Advice to those with low back pain

Answer 13

Encourage self-management
Stay physically active
Exercise

Question 14

Management of nonspecific lower back pain

Answer 14

NSAIDs (paracetamol ineffective) + PPI if > 45
Exercise programme within NHS
Massage

Question 15

Causes of cauda equina

Answer 15

Cancer
Disc prolapse
What else?