Back pain

Question 1

What are some sinister causes of backpain?

Answer 1

• Malignancy
• Cauda Equina
• Spinal trauma
• Spondyloarthritis (inflammatory) Infection

Question 2

What are the red flags for sinister causes of back pain?

Answer 2

• Age <20 or >55
• Systemic
• Constant or progressive pain
• BIlateral or laternating leg pain
• Neurological disturbance (sciatica)
• Immunosuppresion (steroids/HIV)
• Exercise related leg weakness (spinal stenosis)
• Nocturnal pain
• History of malignancy
• Worse pain on being supine
• Fever, night sweats, weight loss
• Abdominal mass
• Thoracic back pain
• Leg claudication

Question 3

What are the main differentials for back pain?

Answer 3

• Generic MSK related back pain
• Prolapsed disc
• Cauda equina (saddle anaesthesia, urinary/faecal

incontinence, sciatica)

• Malignancy
• Discitis
• Fractures
• Trauma
• Ankylosing spondylitis

Question 4

Age determines the most likely causes of backpain.

What are the main causes in 15-30 year olds?

Answer 4

• Generic MSK related back pain
• Prolapsed disc
• Fractures
• Trauma
• Ankylosing spondylitis
• Pregnancy

Question 5

Age determines the most likely causes of backpain.

What are the main causes in 30-50 year olds?

Answer 5

• Degenerative spinal disease
• Prolapsed disc
• Malignancy
  
  • Primary
  • Secondary from:
    
    • Prostate
    • Lung
    • Breast
    • Thyroid
    • Kidney

Question 6

Age determines the most likely causes of backpain.

What are the main causes in >50 year olds?

Answer 6

• Degenerative spinal disease
• Pagets
• Malignancy
• Osteoporotic vertebral collapse
• Myeloma
• Spinal stenosis

Question 7

What investigations should you carry out to diagnose the cause of back pain?

Answer 7

• Relevant tests if you suspect a specific cause
• If red flag symptoms:
  
  • FBC
  • ESR
  • CRP
    
    • Above three for infection, myeloma and tumour
  • CA markers
    
    • PSA
  • U&Es
  • ALP
    
    • For Pagets
• MRI
• X-ray

Question 8

How is non-specific back pain managed?

Answer 8

• Education on self management
  
  • Manual handling techniques
  • Continue normal activites and be active
• Medication
  
  • Regular paracetamol
  • NSAIDs
  • Codeine
  • Low dose amitryptiline or duloxetine if the above fail
• Physiotherapy, acupunction and exercise
• Address psychosocial issues which may predispose people to chronic back pain and disability
• Pain clinic referral
• Surgery

Question 9

What are the two main neurological emergencies?

Answer 9

Cauda equina

Acute cord compression

Question 10

What are the signs and symptoms of cauda equina compression?

Answer 10

• Alternating or bilateral root pain in legs
• Saddle anaesthesia (perianal)
• Loss of anal tone on PR
• Bladder and/or bowel incontinence

Question 11

What are the signs and symptoms of acute cord compression?

Answer 11

• Bilateral pain
• Lower motor neuron signs at the level of compression
• Upper motor neuron signs below
• Sensory loss below
• Sphincter disturbance

Question 12

What are the causes of cauda equina compressiona and acute cord compression?

Answer 12

• Bony metastasis
• Large disc protrusion
• Myeloma
• Cord or paraspinal tumour
• TB
• Abscess

Question 13

Why is it important that cauda equina and cord compression are treated immediately and urgently?

Answer 13

• Prevent irreversible loss of function

Question 14

How are cauda equina and acute cord compression treated?

Answer 14

• Radiotherapy/Chemotherapy for tumours
• Laminectomy for disc protrusion
• Decompression for abscesses