Back Pain Flashcards
Give 4 indications for referral in patients presenting with low back pain
1) Features of cauda equina (immediate)
2) neurological deficit (urgent)
3) Nerve root pain not resolving within 6 weeks
4) Underlying inflammatory disorder (e.g. ankylosing spondylitis)
What are the red flag features of cauda equina?
Saddle anaesthesia
Bladder/bowel dysfunction
What features in the history would indicate a diagnosis of osteoporosis?
- old lady
- smoker
- steroid use
- loss of height
- tenderness over spinous process (fracture)
How would you manage a patient with suspected osteoporosis?
- Refer for DEXA scan (X-ray if fracture suspected)
- Treated with bisphosphonates (alendronate) + vitamin D and calcium supplements
What features in the history would indicate a diagnosis of ankylosing spondylitis?
- young male
- morning stiffness, improves on movement
- night pain
- insidious onset
How would you manage a patient with suspected ankylosing spondylitis?
- ESR
- Joint examination
- Refer to rheumatology
What features in the history would indicate a diagnosis of bony metastases?
- history of cancer (breast, prostate, lung, kidney)
- older
- worsening pain
- hypercalcaemia
- Raised ALP
How would you manage a patient with suspected bony metastases?
- Serum calcium
- Alkaline phosphatase
- PSA
- Prostate examination
- Urgent referral to oncololgy
What features in the history would indicate a diagnosis of spinal stenosis?
- pain relieved by bending forward
- neurogenic claudication (leg pain walking up hill)
How would you manage a patient with suspected spinal stenosis?
- Mild = NSAIDs and physio
- Severe = refer to orthopaedics
What features in the history would indicate a diagnosis of disc prolapse –> radiculopathy
- leg pain
- numbness and tingling in leg
- sudden onest
- worse with laughing/coughing/sneezing
- pain on straight leg raise
How would you manage a patient with suspected disc prolapse –> radiculopathy
- advise to remain active
- paracetamol + NSAIDs
- physiotherapy
- delayed MRI if not improving after 6m
What features in the history would indicate a diagnosis of mechanical back pain?
- localised pain
- worse on movement or sitting/standing for long periods
- specific trigger/precipitating event
- no nerve involvement
How would you manage a patient with suspected mechanical back pain
- advise to remain active
- advise to return to work, even if it causes some pain
- limit heavy lifting
- NSAIDs
- anti-spasmodic (e.g. Baclofen) if muscle in spasm
What screening tool is used to identify patients at risk of developing chronic back pain? How are these patients managed?
- Keele STarT Back screening tool
- Intensive physio and CBT
