Back pain Flashcards by Thivyaa Gangatharan

What would your differentials be if the pain directly overlay the spine?

Spinal fracture

Arthritis

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What would your differentials be if the pain was paraspinal?

Muscle sprain or spasm

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What would your differentials be if the pain was lateral to the spine/in the flank?

Renal pain

pyelonephritis
renal colic

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What would your differentials be if it was pleuritic back pain?

Pulmonary embolism

Pneumonia

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Unilateral flank pain?

Pyelnephritis/renal colic

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What would pain between the scapula suggest?

Spinal fracture
Aortic dissection
MI

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Dfx for pain that is present at rest and wakes the patient at night

Inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis)

Malignancy (e.g. spinal metastases)

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Dfx for pain that is described as burning/shooting in nature

Neuropathic pain e.g. nerve root compression

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Dfx for tearing thoracic back pain

Aortic dissection

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Dfx for sharp non-specific back pain

Spinal fracture
Muscular spasms
PE

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Dfx if the pain radiates to the buttocks or legs?

Sciatic nerve compression

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Dfx for pain in the back that radiates to the ipsilateral groin

Renal colic

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Dfx for back pain that radiates to the chest

Aortic aneurysm

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Dfx for back pain that radiates to the epigastrium

Peptic ulcer disease

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Dfx for back pain that radiates to the abdomen

Constipation
Abdominal aortic aneurysm dissection
Ischaemic bowel

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Dfx for back pain that radiates to the upper or lower limbs

Radiculopathy secondary to spinal nerve root compression

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What might be some relieving factors?

Analgesia (e.g. paracetamol)
Muscle relaxants (e.g. diazepam) 
Lying down

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What are some associated symptoms to ask about?

Motor or sensory disturbances
Urinary retention or incontinence
Haematuria
Fever
Malaise
Weight loss
Early morning stiffness
Muscular spasms

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If back pain is associated with motor or sensory disturbance, what are the differentials?

Nerve root compression (i.e. radiculopathy)

Spinal cord compression (e.g. cauda equina syndrome)

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What’s another name for nerve root compression?

Radiculopathy

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What’s another name for spinal cord compression?

Cauda equina syndrome

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Causes of cauda equina syndrome

Prolapsed intervertebral disc
Displaced vertebral fracture
Haemorrhage
Epidural abscess

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What must you specifically ask about if you’re thinking cauda equina syndrome?

Saddle anaesthesia - i.e. a loss of sensation in the anal/perianal region

Ask if they can feel when they wipe

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Dfx for back pain associated with urinary retention or incontinence

Cauda equina syndrome

Dfx for back pain associated with haematuria

Back trauma UTI Renal tract malignancy

Dfx for back pain associated with fever

UTI Pneumonia Discitis

Dfx for back pain associated with malaise

Discitis | Malignancy

Dfx for back pain associated with weight loss

Malignancy

Dfx for back pain associated with early morning stiffness

Inflammatory arthritis | e.g. rheumatoid arthritis/ankylosing spondylitis

Dfx for back pain associated with muscular spasms

Spinal fracture | Primary muscular injury

List some key features of cauda equina syndrome

``` Bilateral sciatica Urinary retention Incontinence Flaccid paraparesis Impaired reflexes ```

What are the four things you want to rule out when asking about red flags?

Cauda equina Spinal fracture Malignancy Infection

What are the red flags for cauda equina syndrome?

Progressive bilateral neurological deficit in the legs Urinary retention/incontinence/ faecal incontinence Saddle anaesthesia

What are the red flags for spinal fracture?

Sudden onset severe central spinal pain Relieved by lying down History of trauma

Spinal fracture might be relieved by what position?

Lying down

What are the red flags for malignancy?

``` 50 years+ Severe unremitting pain despite position Disturbance of sleep Localised spinal tenderness Unexplained weight loss History of cancer ```

What are the red flags for infective causes of back pain?

``` Fever Tuberculosis or recent UTI Diabetes History of IV drug use HIV infection Use of immunosuppressant medication ```

What are the red flags for epidural abscess?

Fever Back/ neck pain Neuro deficits IV drug use

What are the red flags for acute pancreatitis?

``` Epigastric or LUQ pain radiating to the back Relieved when lean forward N+V, fever, tachycardia Gallstones XS alcohol intake ```

What are the red flags for ruptured AAA?

Abdo/back pain Pulsatile abdo mass Hypotension

Cauda equina causes LMN symptoms or upper motor neuron symptoms? What are these?

``` LMN symptoms: Flaccid paralysis - asymmetrical Decreased or absent reflexes Saddle anaesthesia - asymmetrical Faecal incontinence/urinary retention ```

Cauda equina causes UMN symptoms or upper motor neuron symptoms? What are these?

``` UMN Spastic paralysis - symmetrical Increased reflexes Specific anatomical level symmetrical sensory changes Faecal incontinence/urinary retention ```

Which gene is associated with ankylosing spondylitis?

HLA B27

Which test is used to diagnose ankylosing spondylitis? Explain this test

Schober's test - place two fingers on patient's back, ten cm apart, and ask them to bend Fingers should move more than 15 cm, if not then it's suggestive of spondylitis

What kind of position do patients with ankylosing spondylitis have?

Question mark position

What kind of appearance is the spine on xray for ankylosing spond? What is this caused by?

Calcification of ligaments with ankyloses leads to bamboo spine appearance on X-ray

What are the 5As of extra articular disease for ankylosing spond?

``` Anterior uveitis Apical lung fibrosis Achilles tendinitis Amyloidosis - mucosal and skin lesions Aortic regurgitation (IBD and cauda equine syndrome) ```

``` What systems review questions would you ask for: Systemic CV Resp Gastro GU Neuro MSK Derm ```

Systemic: fevers (e.g. discitis), weight change (e.g. malignancy) Cardiovascular: chest pain (e.g. aortic dissection) Respiratory: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism) Gastrointestinal: abdominal pain (e.g. constipation) Genitourinary: loin pain, haematuria, dysuria (e.g. pyelonephritis) Neurological: headache (e.g. cervicogenic headache), motor or sensory disturbances (e.g. spinal cord compression) Musculoskeletal: trauma Dermatological: rashes (e.g. psoriasis)

Relevant pre-existing conditions?

Previous history of back pain Previous back pain treatments Osteoporosis Trauma Congenital spine problems (scoliosis) Malignancy Recent infections/ immunosuppression CVD Gallstones

What medications might you particularly ask about that might increase risk of fractures?

Corticosteroids

What do you call TB-related bone disease?

Pott's disease

Relevant family history

``` Back problems Inflammatory arthritis Malignancy CVD Osteoporosis ```

Key social history factors - how do these relate to back pain?

Smoking is an important risk factor for malignancy, osteoporosis, bone fractures and aortic aneurysms. Chronic excessive alcohol use is a risk factor for osteoporosis and trauma. Intravenous drug use is a risk factor for discitis

Why might travel/sexual history be relevant?

Travel - TB/musc strain | Sexual history - muscular strain, prengancy

Why would you ask about hobbies?

To identify any risk factors e.g. contact sport

Why does diet and CVD relate to back pain?

Aortic dissection

What else do you need to ask about?

Occupation/housing

What are some differentials for muscular strain?

Prolapsed intervertebral disc Muscular strain Vertebral fracture