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Back pain Flashcards

1
Q

What are 2 groups that back pain can be classified into? 2 forms of classification

A

Neck pain vs lower back pain

With and without radiculopathy

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2
Q

What region of the back does ‘low back pain’ affect?

A

Lumbosacral area, between bottom of ribs and top of legs

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3
Q

What type of back pain is most low back pain termed?

A

Non-specific back pain

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4
Q

What are 2 complications of non-specific back pain?

A
  1. Development of chronicity and depression
  2. Disability and loss of employment
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5
Q

What is the typical picture and course of non-specific back pain? 3 key features

A
  1. Chronic problem in which periods of little pain or disability are interrupted by acute episodes of severe pain
  2. Varies with posture
  3. Exacerbated by movement
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6
Q

What are 4 key aspects of the management of non-specific low back pain?

A
  1. Assess risk of back pain disability using risk stratification tool
  2. Providing adequate analgesia (NSAID first line, codeine with or without paracetamol if NSAID CI or not tolerated). If paraspinal muscles are in spasm, short course of benzodiazepine
  3. Provide info about expected time course, self-help measures, staying active, resuming normal activities, return to work as soon as possible
  4. Offer people at higher risk of back pain disability referral for group exercise and/or CBT and/or physiotherapy
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7
Q

When should you urgently refer someone with low back pain?

A

Refer urgently to neurosurgeon or orthopaedic surgeon if red flags including progressive, persistent, or severe neurological deficit

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8
Q

When should you make a non-urgent referral for non-specific lower back pain? What are 4 services you can refer to?

A

If symptoms not improving or worsening

  1. Group exercise
  2. Cognitive behavioural therapy
  3. Physiotherapy
  4. Specialist low back pain services for assessment
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9
Q

What are 8 examples of specific causes of low back pain?

A
  1. Sciatica
  2. Vertebral fracture
  3. Osteoporosis
  4. Intra-abdominal pathologies (pancreatitis, peptic ulcer, kidney stones)
  5. Ankylosing spondylitis
  6. Shingles (herpes zoster)
  7. Cancer
  8. Infection
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10
Q

What may non-specific low back pain be related to, despite not being attributed to a specific cause?

A

Trauma or musculoligamentous strain

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11
Q

What are 4 risk factors for the development of non-specific low back pain?

A
  1. Obesity
  2. Physical inactivity
  3. Occupational factors (e.g. heavy lifting)
  4. Depression and other psychological conditions
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12
Q

How long does it take for most episodes of non-specific back pain to resolve with self care?

A

4 weeks

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13
Q

What are 4 risk factors for long-term pain and functional disability due to low back pain?

A
  1. Pain lasting longer than 12 weeks
  2. Psychosocial distress
  3. Maladaptive coping strategies such as avoidance of work, movement, or other activities due to fear of exacerbating back pain
  4. Pain coping characterised by excessively negative thoughts about the future (‘catastrophizing’)
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14
Q

What are 6 things to ask about in the low back pain history?

A
  1. Type of pain
  2. Duration of symptoms
  3. Aggravating and relieving factors
  4. Associated symptoms
  5. Radiation of pain
  6. Night pain
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15
Q

What are 8 parts of the examination in low back pain?

A
  1. Observe gait and posture
  2. Inspect for skin changes: bruising, rash, deformity or swelling
  3. Neurological exam: loss of sensation
  4. Change to reflexes
  5. Limitation of range of movement
  6. Straight leg raise
  7. Tenderness
  8. Fever
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16
Q

What is part of the examination to consider in low back pain that doesn’t have to be carried out in primary care?

A

Assessment of anal tone

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17
Q

What are 4 causes of back pain that you are trying to rule out with red flag symptom questions?

A
  1. Cauda equina syndrome
  2. Cancer of the spines
  3. Spinal fracture due to trauma or osteoporotic collapse
  4. Spinal infection
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18
Q

What are 6 examples of intra-abdominal causes of low back pain?

A
  1. Peptic ulcer
  2. Pancreatitis
  3. Kidney stones
  4. Pyelonephritis
  5. Prostatitis
  6. Pelvic infection
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19
Q

What are 4 symptoms that should make you suspect ankyosing spondylitis as a cause of low back pain?

A
  1. Pain at night not relieved when person is supine
  2. Stiffness in morning that is relieved with movement/ exercise
  3. Gradual onset of symptoms
  4. Symptoms that have lasted for more than three months
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20
Q

What are 6 features that could suspect osteoporosis as a cause of low back pain?

A
  1. Non-specific pain
  2. Localised tenderness if vertebral fracture
  3. Female sex
  4. Advancing age
  5. Current or previous smoking history
  6. Use of corticosteroids
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21
Q

When should you suspect herpes zoster (shingles) as a cause low back pain?

A

If person has unilateral pain and rash in the distribution of a dermatome

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22
Q

What are 5 symptoms that suggest low back pain is caused by sciatica?

A
  1. Unilateral leg pain radiating below knee to foot or toes
  2. Low back pain - less severe than leg pain
  3. Numbness, tingling and muscle weakness in distribution of a nerve root (dermatome)
  4. Positive straight leg raising test - causes greater pain radiation below knee and/or more nerve compression symptoms
  5. Extensor (upgoing) plantar response - when lateral part of sole of foot is stimulated, toes extend and fan outwards
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23
Q

When should you perform an x-ray for lower back pain?

A

If suspicion of specific pathology, such as compression fracture due to osteoporosis

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24
Q

What are 5 red flag symptoms to ask about to exclude cauda equina syndrome?

A
  1. Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  2. Recent-onset urinary retention and/or urinary incontinence
  3. Recent-onset faecal incontinence
  4. Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
  5. Unexpected laxity of anal sphincter
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25
Q

What causes urinary retention in cauda equina syndrome?

A

Bladder distension because sensation of fullness is lost

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26
Q

What causes urinary incontinence in cauda equina syndrome?

A

Loss of sensation when passing urine

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27
Q

What causes faecal incontinence in cauda equina syndrome?

A

Loss of sensation of rectal fullness

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28
Q

What is cauda equina syndrome?

A

Nerve roots of the cauda equina are compressed (L2-coccygeal) most commonly due to massive herniated disc in lumbar region, and disrupt motor and sensory function to the lower extremities and bladder

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29
Q

What is the commonest cause of cauda equina syndrome?

A

Massive herniated disc in lumbar region

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30
Q

What are 5 red flags to rule out that would point to spinal fracture as a cause of lower back pain?

A
  1. Sudden onset severe central spinal pain relieved by lying down
  2. History of major trauma e.g. RTA, fall
  3. Minor trauma, or strenuous lifting in pt with osteoporosis/ use corticosteroids
  4. Structural deformity of spine e.g. step from one vertebra to adjacent vertebra
  5. Point tenderness over a vertebral body
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31
Q

What are 9 red flags to rule out that would point to cancer as a cause of lower back pain?

A
  1. Age >50y
  2. Gradual onset of symptoms
  3. Severe unremitting pain that remains when supine, aching night pain that prevents/disturbs sleep
  4. Pain aggravating by straining e.g. at stool or when coughing or sneezing
  5. Thoracic pain
  6. Localised spinal tenderness
  7. No symptomatic improvement after 4-6 weeks of conservative low back pain therapy
  8. Unexplained weight loss
  9. Past history of cancer esp breast, lung, GI, prostate, renal, thyroid
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32
Q

What are 5 red flags to rule out that would point to infection as a cause of lower back pain?

A
  1. Fever
  2. Tuberculosis, or recent UTI
  3. Diabetes
  4. History of IV drug use
  5. HIV infection, use of immunosuppressants, or person otherwise immunocompromised
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33
Q

How should you manage a patient with low back pain with red flag symptoms and signs?

A

Admit or refer urgently for specialist assessment, or imaging, using clinical judgement

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34
Q

What are 5 broad aspects of the managemet of non-specific low back pain?

A
  1. Assess with risk stratification tool such as STarT Back
  2. Self management advice
  3. Analgesia
  4. Advise to follow up if symptoms persist or worsening after 3-4 weeks, and report any red flags
  5. If at higher risk of poor outcome, refer for group exercise/ CBT/ physiotherapy
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35
Q

What is a key risk stratification tool for non-specific low back pain and what is it for?

A

STarT Back - to identify modifiable risk factors (biomedical, psychological and social) for back pain disability

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36
Q

What are the 4 most important things to guide management in suspected non-specific low back pain?

A
  1. Quality of life
  2. Pain severity
  3. Function
  4. Psychological distress
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37
Q

What is the suggested analgesia management of low back pain?

A
  • NSAID first line e.g. ibuprofen or naproxen
  • If NSAID CI, not tolerated, or ineffective: codeine with or without paracetamol
  • If muscle spasm: short course of benzodiazepine
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38
Q

What dose of NSAID should be used for low back pain? What should be offered in addition to the NSAID?

A

Lowest possible dose for shortest possible time

Should offer gastroprotective treatment while NSAID being used

39
Q

What are 2 risks of prescribing codeine with or without paracetamol for low back pain?

A
  1. Opioid dependence
  2. Constipation
40
Q

What are 7 types of drugs that should not be offered for low back pain?

A
  1. Paracetamol alone (only with codeine)
  2. Opioids - for acute or chronic low back pain
  3. SSRIs
  4. SNRIs
  5. TCAs
  6. Gabapentinoids
  7. Antiepileptics
41
Q

If a patient has muscle spasm in association with back pain what should you offer and what course?

A

Benzodiazepine e.g. diazepam 2mg up to 3x a day for up to 5 days if not contraindicated

42
Q

What additional care should be offered to patients with low back pain at higher risk of a poor outcome? 4 things

A
  1. Referral for group exercise programme (biomechanical, aerobic, mind-body)
  2. Referral to a physiotherapist for manual thearpy (spinal manipulation, mobilisation or massage) as part of treatment package including exercise
  3. Referral for CBT if significant psychosocial obstacles e.g. avoiding normal activities
  4. Promote and facilitate return to work or normal ADLs
43
Q

What are 8 pieces of self-management advice to give for non-specific low back pain?

A
  1. Advise acute non-specific low back pain not caused by serious structural damage
  2. Most people can reasonably be expected to recover from an episode within a period of weeks
  3. Offer information leaflets on exercises that may help
  4. Local heat may relieve pain and muscle spasm
  5. Encourage to stay active, resume normal activities, return to work. Don’t need to be pain free to do this
    • will reduce risk of recurrence
  6. Prolonged bed rest not recommended
  7. Normal movements may produce some pain which should not be harmful if activities resumed gradually
  8. Work adjustments can make early return to work possible, may be arranged by occupational health
44
Q

What are the 3 conditions which must be met for referral for assessment for radiofrequency denervation for chronic low back pain to be made?

A
  1. Non-surgical treatment has not worked
  2. Main source of pain thought to come from structures supplied by medial branch nerve
  3. Person’s pain rated as 5 or more on visual analogue scale, or equivalent, at time of referral
45
Q

What is sciatica?

A

Term for symptoms of pain, tingling and numbness which arise from nerve root compression or irritation in the lumbosacral spine

46
Q

What are 6 of the typical symptoms of sciatica?

A
  1. Lower back pain (less severe than leg pain if present)
  2. Unilateral leg pain, worse when sitting down, radiating below knee to foot or toes
  3. Numbness, tingling, muscle weakness in distribution of dermatome e.g. extends to below the knee, including buttocks, across back of thigh, to outer calf, and often to feet and toes
  4. Loss of tendon reflexes in distribution of single nerve root
  5. Positive SLR test
  6. Extensor plantar response
47
Q

What are 5 causes of sciatica?

A
  1. Herniated intervertebral disc - 90%
  2. Spondylolisthesis - proximal vertebra moves forward relative to a distal vertebra
  3. Spinal stenosis e.g. due to congenital stenosis and spondylolisthesis
  4. Infection (rare) e.g. discitis, vertebral osteomyelitis, spinal epidural abscess
  5. Cancer (rare)
48
Q

What is the commonest cause of sciatica?

A

Herniated intervertebral disc - about 90%, most commonly at L4/5 and L5/1 levels

49
Q

What is spondylolisthesis?

A

When a proximal vertebra moves forward relative to a distal vertebra

50
Q

What are 2 causes of spinal stenosis (which can lead to sciatica)?

A
  1. Congenital stenosis
  2. Spondyolisthesis
51
Q

What are 3 types of stenosis and what can each cause?

A
  1. Lateral recess stenosis - sciatica
  2. Foraminal stenosis - sciatica
  3. Central spinal stenosis - spinal claudication (bilateral calf pain, paraesthesia, numbness on walking)
52
Q

What causes spinal claudication and what are 3 key symptoms?

A

Central spinal stenosis

  1. Bilateral calf pain
  2. Paraesthesia
  3. Numbness on walking
53
Q

What are 3 types of infection which could cause sciatica?

A
  1. Discitis
  2. Vertebral osteomyelitis
  3. Spinal epidural abscess
54
Q

What are 5 possible complications of sciatica?

A
  1. Permanent nerve damage with possible sensory deficits
  2. Motor weakness such as foot drop
  3. Increased risk of permanent damage to compressed nerve if significant muscle weakness or wasting and/or loss of tendon reflexes
  4. Anxiety, depression, psychosocial impact on family
  5. Time off work, reduced productivity, loss of employment
55
Q

What are 6 risk factors for sciatica?

A
  1. Strenuous physical activity e.g. frequent heavy lifting, especially bending, twisting, and jogging
  2. Whole body vibration e.g. due to driving or operating machinery
  3. Smoking
  4. Obesity
  5. Occupational factors
  6. General health
56
Q

What is the prognosis of sciatica?

A

Episodes are usually transient with rapid improvements in pain and disability seen within a few weeks to a few months. However, recurrence of symptoms is common (50% within 2 years)

57
Q

What assessment of a patient with suspected sciatica should you perform to diagnose it?

A
  • Examination of hips and knees
  • Neurological examination of lower limb
  • Positive straight leg test - raising leg while straight causes greater pain radiation below knee and/or more nerve compression symptoms
  • Extensor plantar response - when lateral part of sole stimulated, toes extend and fan outwards (may indicate UMN lesion)
58
Q

What are the 2 key positive findings in examination of a patient with sciatica?

A
  1. Positive straight leg test - raising leg while straight causes greater pain radiation below knee and/or more nerve compression symptoms
  2. Extensor plantar response - when lateral part of sole stimulated, toes extend and fan outwards (may indicate UMN lesion)
59
Q

Should you perform x-ray to confirm diagnosis of sciatica?

A

No, not routinely

60
Q

What are 9 differentials for sciatica?

A
  1. Refererd pain from hip osteoarthritis
  2. Sacroiliitis in ankylosing spondylitis and other spondyloarthropathies
  3. Intervertebral facet joint pain
  4. Trochanteric bursitis
  5. Piriformis syndrome (sciatic nerve compressed or irritated where covered by piriformis muscle)
  6. Peroneal palsy or other neuropathies e.g. nerve entrapment at fibular head
  7. Spinal claudication
  8. Aseptic necrosis of femoral head
  9. Myelopathy or higher cord lesion
61
Q

What assessment tool can be used to risk stratify patients with sciatica and what does this identify?

A

STarT Back - identifies modifiable risk factors (biomedical, psychological and social) for back pain disability

62
Q

What are 5 key aspects of the management of sciatica and what is it similar to?

A

Management of non-specific low back pain -

  1. Self management advice
  2. analgesia
    • same as for non-specific but limited evidence of benefit from NSAIDs - be more cautious esp re side effects
  3. If high risk of poor outcome, group exercise ± physio ± CBT
  4. advise to seek follow up if symptoms persist/ worsen: 1-2 weeks (shorter time frame)
  5. advise to report any red flag symptoms and signs
63
Q

What are 7 pieces of self-management advise to give a patient with sciatica?

A
  1. symptoms usually settle within 4-6 weeks but may persist for longer in some people
  2. local heat may relieve pain/muscle spasm
  3. small firm cushion between knees when sleeping on side/firm pillows propping up knees when lying on back may help
  4. offer PILs on exercises
  5. don’t recommend prolonged bed rest, normal movements may produce pain which should not be harmful if gradual increased activities
  6. don’t need to be pain free before returning to work. work adjustments/ occupational health can help
  7. keep as active as possible and exercise regularly to reduce recurrence
64
Q

What safety netting should you give in sciatica?

A

Seek follow up if symptoms persist or worsen after 1-2 weeks, report any red flag symptoms and signs

65
Q

In addition to the pain medication for non-specific low back pain, what can be used to treat sciatica?

A

Neuropathic pain drugs e.g. TCAs (not gabapentinoids, antiepilieptics, benzos or corticosteroids)

66
Q

When should you consider arranging specialist referral for sciatica?

A

If progressive, persistent, or severe neurological deficit, admit or refer urgently to neurosurgery or orthopaedics, depending on clinical judgement and local pathways

67
Q

If pain or functional impairment persists with sciatica after, what are 4 options?

A
  1. Offer referral for group exercise programme / CBT / physio. combined physical and psychological recommended if persistent
  2. specialist low back pain and sciatica service for assessment for epidural corticosteroid/local anaesthetic injection
  3. consider referral for assessment for radiofrequency denervation
  4. consider referral for assessment for surgical spinal decompression when non-surgical treatment has not improved pain or function
68
Q

What are 4 differentials for neck pain?

A
  1. Non-specific - when no specific cause found
  2. Whiplash injury
  3. Acute torticollis
  4. Cervical radiculopathy
69
Q

What are 8 red flags for neck pain?

A
  1. Neurological symptoms and signs
  2. Malaise
  3. Fever
  4. Unexplained weight loss
  5. Unremitting pain affecting sleep
  6. History of violent trauma
  7. Neck surgery
  8. Risk factors for osteoporosis
70
Q

What is the management of non-specific neck pain? 9 points

A
  1. reassurance - usually resolves in a few weeks
  2. oral analgesics e.g. ibuprofen, paracetamol, ocdeine
  3. topical NSAID
  4. encourage activity and return to normal lifestyle
  5. muscle relaxants
  6. physio/ stretching and strengthening exercise
  7. firm pillow
  8. psychologist if appropriate
  9. occupational health
71
Q

When should you consider referral with chronic neck pain and to where?

A

Chronic neck pain >12 weeks, referral to pain clinic

72
Q

What is cervical radiculopathy?

A

Term used to describe pain and weakness and/or numbness in one or both of the upper extremities which corresponds to the dermatome of the involved cervical nerve root

73
Q

What are the commonest causes of cervical radiculopathy?

A

Degenerative changes:

Cervical disc herniation and spondylosis (degeneration of intervertebral discs)

74
Q

In which age group is cervical radiculopathy most common?

A

Age 50-54 years, more common in men

75
Q

What are 4 tests to perform to help identify cervical radiculopathy?

A
  1. Spurling test
  2. Arm squeeze test
  3. Axial traction test
  4. Upper limb neurodynamic tests
76
Q

What key factor determines the management of cervical radiculopathy?

A

Duration: 4-6 weeks or less vs 4-6 weeks or more

77
Q

Should you perform x-rays/imaging for cervical radiculopathy?

A

No, not normally required to diagnose or manage

78
Q

What are 5 elements of the management of cervical radiculopathy last has lasted for less than 4-6 weeks?

A
  1. Providing reassurance, information and advice
  2. Offering oral analgesia to relieve symptoms
  3. Considering offering amitriptyline, duloxetine, pregabalin or gabapentin
  4. Consider muscle relaxant
  5. Consider referral for physio
79
Q

What is the management of cervical radiculopathy that has been present for 4-6 weeks or more? When else would you perform this management?

A

Refer for MRI and invasive procedures to be considered

Same for objective neurological signs

80
Q

What is the time frame of acute torticollis?

A

Less than 6 weeks duration

81
Q

What is thought to cause acute torticollis?

A

Minor local musculoskeletal irritation causing pain and spasm in neck muscles; often not known. May be issue with posture e.g. poor positioning at computer/ inappropriate seating, sleeping without adequate neck support, carrying heavy unbalanced loads

82
Q

What are 4 typical features of acute torticollis?

A
  1. Sudden onset of severe unilateral pain
  2. Restricted and painful neck movements
  3. Diffuse tenderness on involved side
  4. Palpable spasm
83
Q

What are 6 aspects of the management of acute torticollis?

A
  1. Reassurance that symptoms usually resolve within 24-48 hours
  2. Offer oral analgesics e.g. paracetamol or ibuprofen ± codeine and muscle relaxants
  3. Offer physio referral
  4. Advise using intermitent heat or cold pack, firm pillow, good posture
  5. Advise against routine use of soft cervical collar, and driving (can’t rotate head to see traffic)
  6. Refer if red flag symptoms (fever, neck stiffness, unexplained weight loss, severe neck tenderness, photophobia or phonophobia, neurological problems)
84
Q

What is the definition of whiplash?

A

An acceleration-deceleration mechanism of energy transer to the neck, which may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other activities

Sudden or excessive hyperextension, hyperflexion, or rotation of neck and causes neck pain and other symptoms

85
Q

What are 11 signs and symptoms of whiplash?

A
  1. Neck pain, may refer to shoulder or arm
  2. Headache
  3. Reduced range of neck movements
  4. Muscular spasm
  5. Stiffness
  6. Deafness
  7. Tinnitus
  8. Dysphagia and nausea
  9. Fatigue, dizziness, paraesthesiae
  10. Memory loss
  11. temporomandibular joint pain
86
Q

What can occur as a follow on from whiplash and what impacts its prognosis?

A

Whiplash associated disorders (WAD): bony or soft-tissue injuries which may lead to variety of clinical manifestations

Personal and societal factors have large impact on course of recovery

87
Q

What are 5 important things that the assessment of suspected whiplash should include?

A
  1. Take detailed history, ideally use Visual Analogue scale to assess intensity of pain
  2. Identify and urgently refer if features of serious head or neck injury
  3. Apply Canadian C-spine rule to identify and refer people at risk of cervical spine radiology
  4. Assess disability using Neck Disability Index (NDI)
  5. Classify the WAD grade using Quebec Task Force Classification
88
Q

What are 5 important aspects of the management of whiplash?

A
  1. Offer self care advice and provide reassurance symptoms are self-limiting
  2. Encourage early return to usual activities and early mobilisation and discouraging use of soft collars
  3. Offer analgesia to relieve symptoms e.g. ibuprofen, paracetamol, or codeine
  4. Consider referral to physiotherapy
  5. Consider referral to psychologist
89
Q

What follow up of whiplash-associated disorders (WAD) should be performed?

A

Follow up at intervals of at least 7 days, 3 weeks, 6 weeks and 3 months

90
Q

When should you consider referral to a specialist in WAD? 2 scenarios

A
  1. Pain intensity greater than 5 out of 10 on VAS
  2. Disability related to neck pain which is greater than 15/50 on NDI (neck disability index)
91
Q

When should you refer to a pain clinic for multidisciplinary pain management for whiplash?

A

if people haven’t responded to treatment at 12 weeks follow up

92
Q

What are yellow flags and what can be used to help assess them?

A

Factors that suggest a patient is less likely to recover, more likely to develop chronic back pain, depression and disability

Keele STarT Back tool

93
Q

What are 6 yellow flag symptoms that the Keele STarT Back tool asks about?

A
  1. Only walking short distances due to back pain
  2. Dressing more slowly due to back pain
  3. Thinking it’s not safe to be physically active due to condition
  4. Worrying thoughts going through mind a lot of the time
  5. Feeling it’s terrible and never going to get better
  6. Stopped enjoying activities they used to
94
Q

What is a good alternative test to the Straight Leg Raise useful in the elderly?

A

Slump test - can do in chair

GP (43 decks)

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