Back Pain

Question 1

What are the 3 main functions of the spine?

Answer 1

1. to allow for a range of movement 2. to protect the spinal nerves 3. to act as a shock absorber

Question 2

What are the 3 main curves in the spine?

Answer 2

1. cervical lordosis
2. thoracic kyphosis
3. lumbar lordosis

Question 3

Why is the cervical spine the most flexible part of the spine?

Answer 3

it has relatively thick intervertebral discs in relation to the size of the adjacent vertebrae

Question 4

What happens to the lumbar lordosis with age?

Answer 4

it becomes more flattened

Question 5

Why do the intervertebral discs become more vulnerable to injury as the day progresses?

Answer 5

in the morning they are swollen with water

the annulus and intervertebral ligaments resist bending more strongly

Question 6

Label the parts of the intervertebral disc

Answer 6

Question 7

What happens to the intervertebral discs with increasing age?

Answer 7

the discs lose water and lose strength

they become increasingly thinner

Question 8

What changes occur in the spine as a result of vertebral disc thinning with increasing age?

Answer 8

1. vertebral end plates and underlying bone structure loses strength
2. repetitive loading/trauma can result in annular tears in the discs
3. dryer/weaker discs result in slacker ligaments
4. the spine becomes less stable

Question 9

What are osteophytes?

How do they affect the joints in the spine?

Answer 9

they are nodules of bone that grow to try and stabilise the spine after damage

this leads to increased load over the facet joints

Question 10

What can result as a consequence of osteophyte growth in older people?

Answer 10

increased load over the facet joints leads to degeneration of the facet joints

this can cause facet joint osteoarthritis

Question 11

What are the clinical implications of changes in the spine that occur with age?

Answer 11

1. loss of movement
2. muscle weakness and wasting

there is pain due to the lack of movement of the back

pain prevents patients from exercising, which makes the pain even worse

Question 12

What are the major two messages for patients with lower back pain?

Answer 12

keep flexible and keep strong

patients need to keep moving to increase the strength of the back, as this prevents the pain from getting worse

Question 13

What are the 4 main factors that influence back pain?

Answer 13

1. genetics
2. environment - calcium intake, job, sporting activities
3. body weight - more common in obese patients
4. muscle strength

Question 14

Why is mechanical loading good at preventing lower back pain?

Answer 14

mechanical loading strengthens the vertebral bodies and increases the water content within the discs

gravity and mechanical force stimulates osteoblast cells to build up the spine

overloading should be avoided

Question 15

How does back pain affect absences from work in the UK?

Answer 15

back pain is the largest cause of absence from work in the UK

Question 16

What are the 6 main risk factors for lower back pain at work?

Answer 16

1. heavy physical jobs
2. lifting
3. driving to work
4. previous episodes of lower back pain
5. mental health
6. posture - laptops, seating, desk set-up

Question 17

What is important to remember when making a “diagnosis” of lower back pain?

Answer 17

low back pain is a SYMPTOM and not a disease

Question 18

What are the 3 ways in which lower back pain can be classified?

Answer 18

1. simple backache
2. nerve root involvement
3. possible serious spinal pathology

Question 19

When taking a mechanical (simple) back pain history, what is significant about when the first and recurrent episodes occur?

Answer 19

the first episode is often a sudden onset while lifting/twisting/turning

recurrent episodes have decreasing inter-episode frequency

Question 20

Where is the pain in mechanical (simple) back pain?

What is it related to?

Answer 20

the pain is variable and related to posture/position

it may radiate to the buttock or leg

it is less painful when lying flat

Question 21

When is mechanical (simple) back pain better and worse?

Answer 21

it is often worse at the end of the day and better with lying down/resting

Question 22

What is the initial treatment for lower back pain?

Answer 22

simple analgesics

physiotherapy is recommended if symptoms have been lasting more than a few days

rest for no longer than 1-3 days

Question 23

When is secondary care referral recommended in lower back pain?

Answer 23

if the pain has been going on for 6 weeks or more

Question 24

Why are cases of suspected lower back pain rarely X-rayed?

Answer 24

100% of elderly patients over 65 have radiological changes including arthritis, disc narrowing and osteophytes

There is no need for an X-ray as degenerative changes in the spine are expected

Question 25

What are the 5 drugs that are given for treatment of lower back pain?

Answer 25

1. paracetamol 2. NSAIDs 3. opioids 4. anti-depressants - amitriptyline, duloxetine 5. nerve modulators - gabapentin, pregabalin

Question 26

Which drugs should be avoided in elderly patients with lower back pain?

Answer 26

opioids are addictive and should be avoided as they can make elderly people confused NSAIDs should be avoided in patients with hypertension, and elderly people as they are more prone to stomach ulcers

Question 27

Why is amitriptyline (anti-depressant) used in treatment for lower back pain?

Answer 27

it relaxes the muscles and helps patients to sleep (not as an antidepressant)

Question 28

What is the origin of the sciatic nerve?

Answer 28

L4 to S3

Question 29

Where does pain occur in sciatica?

Answer 29

pain radiates from the back to the leg below the knee it is NOT sciatica if the pain does not go past the knee

Question 30

What are associated symptoms of sciatica?

Answer 30

1. may be associated with pins and needles in the leg 2. may be associated with numbness and weakness

Question 31

What is the commonest neurological sign in sciatica?

Answer 31

loss of ankle jerk and foot drop

Question 32

What are the red flag symptoms relating to back pain and past medical history?

Answer 32

1. history of carcinoma 2. UTI or other infection 3. history of IV drug abuse, HIV positivity or immunosuppression

Question 33

What are the other red flag symptoms associated with lower back pain?

Answer 33

1. age at first onset - young or old 2. weight loss 3. constant (24h) pain for more than 1 month 4. no response to treatment 4. pain worse at rest - this could be inflammatory back pain

Question 34

What are the 5 cancers that are most likely to have bone metastases?

Answer 34

1. breast 2. bronchus (Lung) 3. byroid (thyroid) 4. bidney (kidney) 5. brostate (prostate)

Question 35

What are the early signs that may suggest bone metastases?

Answer 35

if the back pain wakes you up at night, does not respond to normal pain killers and is getting gradually worse

Question 36

What is the onset of inflammatory back pain like? When is it better and worse?

Answer 36

the onset is insidious there is nocturnal pain and early morning stiffness pain gets better with exercise and worse with rest

Question 37

Where does the pain radiate to in inflammatory back pain?

Answer 37

if it affects the sacroiliac joints, it can cause back and buttock pain the pain in the buttocks tends to alternate from one side to the other

Question 38

Which people tend to be affected by axial spondyloarthritis? What does is affect?

Answer 38

if affects young people - men more than women it causes pain and stiffness in the spine

Question 39

What symptoms are associated with axial spondyloarthritis?

Answer 39

it is a large joint arthritis that causes: 1. enthesitis 2. iritis 3. FH of associated diseases - IBD and psoriasis

Question 40

What happens to the ligaments in axial spondyloarthritis? What usually causes this?

Answer 40

the ligaments down the front and back of the spine fuse and become bony this produces a rigid spine this can occur from inflammatory back pain that hasn't been treated

Question 41

What is enthesitis?

Answer 41

inflammation where the tendons attach onto the bones

Question 42

What is shown in this X-ray?

Answer 42

axial spondyloarthritis

Question 43

What are the main risk factors for osteoporosis?

Answer 43

1. age 2. being female 3. smoking 4. steroids 5. alcohol 6. family history 7. inflammatory conditions

Question 44

What usually occurs, leading to a diagnosis of osteoporosis?

Answer 44

simple lifting and bending can lead to fractures most people don't know they have osteoporosis until this occurs

Question 45

What causes osteomalacia?

Answer 45

a lack of vitamin D this may be due to diet or lack of sunlight

Question 46

What is involved in Paget's disease?

Answer 46

the femoral head is thickened due to increased bone density there is increased bone growth in certain areas

Question 47

What are the symptoms of Paget's disease? Who is usually affected?

Answer 47

prevalence increases with age it is often asymptomatic but patient's have raised alkaline phosphatase

Question 48

How is Paget's disease treated? What can it cause if it is not treated?

Answer 48

it is treated with an IV infusion that works for 3-5 years it can cause spinal stenosis if untreated

Question 49

What is typically seen in a neoplastic/infection back pain history?

Answer 49

* slow, insidious onset * slow deterioration * pain is present for 24 hours (all the time) * weight loss * occasional fever * disturbed sleep

Question 50

What causes cauda equina syndrome?

Answer 50

the spinal cord finishes at L1 - the cauda equina are the long nerve roots that come down from this level damage to the bottom of the spine or prolapse can press on the cauda equina

Question 51

What are the symptoms of cauda equina syndrome?

Answer 51

1, loss of anal sphincter tone or faecal incontinence 2. saddle anaesthesia (numbness between the legs) 3. difficulty with micturition (urination) 4. low back and/or leg pain