Back pain Flashcards
Spinal stenosis
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
Facet joint
May be acute or chronic
Pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back
Ankylosing spondylitis
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
Peripheral arterial disease
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
What are the red flags in back pain?
Red flags for lower back pain age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever Thoracic pain Age <20 or >55 years Non-mechanical pain Pain worse when supine Night pain Weight loss Pain associated with systemic illness Presence of neurological signs Past medical history of cancer or HIV Immunosuppression or steroid use IV drug use Structural deformity
How would a prolapsed disc present?
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.
Features
leg pain usually worse than back
pain often worse when sitting
L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
What is first line treatment for simple lower back pain?
NSAIDS (naproxen or ibuprofen possibly with PPI. Benzodiazepines considered in spasm. Epidural injection of local anaesthetic can be given for acute severe sciatica.
When should an MRI be offered in back pain?
only if it will change action and to those with suspected malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected.
Advice to patients with low back pain?
Encourage self-management and stay physically active with exercise.
What are the features of discitis
back pain, pyrexia, rigors, sepsis and neuro features if epidural abscess develops.
What causes discitis?
Staph aureus, viral, TB, aseptic
