Back pain

Question 1

List red flags for sinister causes of back pain

Answer 1

<20yrs or >55yrs
Acute onset in elderly
Constant/progressive pain
Nocturnal pain
Pain worse on supine
Fever, night sweats
Hx of malignancy 
Thoracic back pain 
Abdo mass
Morning stiffness
Bilateral/alternating leg pain
Neuro disturbance (inc sciatica)
Sphincter disturbance 
Current/recent infection
Immunosuppression
Leg claudication on exercise-related leg weakness/numbness

Question 2

What should you include on examination and why?

Answer 2

1. Lumbar forward/lateral flexion + extension (schobers test)
2. Palpate down length of spine, including spinous processes, paraspinal muscles + sacroiliac joints (sacroiliacs)
3. Lower limb neuro exam
4. DRE for perianal tone and sensation
5. Nerve root pain - dermatomal + worsened by coughing or bending forward
6. Straight leg test + femoral stretch test
7. Signs of generalise disease - pain may be referred

Question 3

What is the straight leg test? What nerve roots does it test and what does a positive result mean?

Answer 3

Pt supine, raise leg w knee extended
+ve if leg pain, can be made worse if foot is dorsiflexed (Lasegues sign)
Tests L4,L5,S1
Suggests irritation to sciatic nerve, could be caused by lumbar disc prolapse

Question 4

What is the femoral stretch test? What nerve roots does it test and what does a positive test mean?

Answer 4

Anterior thigh pain on passive hip extension with patient prone + knee flexed
Tests L2-L4 for disc protrusion and femoral nerve injury

Question 5

What are the main causes of back pain in 15-30yrs

Answer 5

prolapsed disc
trauma
fractures
ank spond
spondylolisthesis
pregnancy

Question 6

What are the main causes of back pain in 30-50yrs

Answer 6

degenerative prolapsed disc

malignancy (primary or secondary - lung breast prostate thyroid kidney)

Question 7

What are the main causes of back pain in >50

Answer 7

degenerative 
osteoporotic vertebral collapse
pagets
malignancy
myeloma 
spinal stenosis

Question 8

What investigations would you consider in back pain?

Answer 8

1. FBC, CRP, ESR (myeloma, infection, tumour)
2. U+E
3. ALP (pagets)
4. Serum/urine electrophoresis (myeloma)
5. PSA
6. XR - bony abnormalities and fractures
7. MRI - detects prolapse + compression, cancer, infection or inflammation

Question 9

What is the general management of back pain (non-specific, not an emergency)

Answer 9

1. Education and self management
2. Keep on w normal activities
3. Regular paracetamol +/- NSAIDs +/- codeine
4. Low dose amitriptyline/duloxetine if above fail
5. Physio, acupuncture, exercise programme
6. Address psychosocial issues
7. Pain clinic or surgical options if sx intractable

Question 10

What are neurosurgical emergencies? How do they tend to present?

Answer 10

1. Acute caudal equine compression - alternating/bilateral root pain in legs, saddle anaesthesia, loss of anal rtone on pr, bladder +/- bowel incontinence
2. acute cord compression - bilateral pain, LMN signs at level of compression, UMN and sensory loss below, sphincter disturbance

Question 11

What are the causes of neurosurgical emergencies?

Answer 11

Bony metastasis
Large disc protrusion
Myeloma
Cord or paraspinal tumor
TB 
Abscess

Question 12

What are the possible treatments for neurosurgical emergencies relating to the cause?

Answer 12

disc protrusion - laminectomy
Tumours - radiotherapy
Abscesses - decompression