Back Pain

Question 1

Red Flags (8)

Answer 1

Systemic Upset
- Fever
-Night sweats
-Weight loss
-Fatigue
-Malaise
New back pain in elderly (>60)
Back pain in the young (<20)
Pain constant, severe or worse at night
Saddle anaesthesia
Bladder/bowel upset
History of cancer
History of steroids

Question 2

Myotome Reflexes (4)

Answer 2

L1/2
- Hipe flexion

L3/4
- Knee extension

L5
-Foot dorsiflexion

S1/2
- Ankle plantar flexion

Question 3

Investigations

Answer 3

MRI 1st Line

• Lots of flash positives
• Disc inflammation (hamburger appearance)

Diagnostic Facet Infection
-Injection of steroids in the facet joint to test if there is improvement

Question 4

Sciatica

Answer 4

Buttock &/or leg pain in a specific dermatomal distribution coupled with neurological disturbance of the L4,L5 or S1 nerve roots

Pain radiates down the sensory aspect of the sciatic nerve

Question 5

Sciatica Aetiology

Answer 5

Osteoarthritis

- Osteophytes can impinge on nerve roots causing sciatica

Question 6

Sciatica Treatment

Answer 6

Analgesia
Maintaining mobility
Physio 
Drugs for neuropathic pain 
- Gabapentin
-Pregabalin
-Amitryptiline
Surgery
-Surgical decompression for OA induced sciatica

Question 7

Prolapsed Disc Aetiology

Answer 7

Nucleus pulpous may herniate through a tear in annulus fibrosis which can impinge on nerve roots

Question 8

Characteristics of prolapsed disc

Answer 8

Pain in dermatomal distribution

Reduced power in myotomal distribution

neuralgic burning or severe tingling pain which radiates to the back of the thigh below the knee

Question 9

Prolapsed Disc Common sites

Answer 9

L4/L5/S1 nerve roots
L3/L4 prolapse
L4/L5 prolapse
L5/S1 Prolapse

Question 10

Signs of L3/l4 Prolapsed disc

Answer 10

L4 root entrapment
Pain down to medial ankle
Loss of quadriceps power
Reduction in knee jerk

Question 11

Signs of L4/L5 prolapse

Answer 11

L5 root entrapment
Pain down to foot dorm
Loss of power to
- extensor hallicus longus
-tibialis anterior

Question 12

Signs of L5/S1 prolpase

Answer 12

S1 root entrapment
Pain down to sole of foot
Reduction in plantarflexion

Question 13

Prolapsed Disc Prolapse
1st line (5)
2nd Line (6)

Answer 13

1st Line

• Short bed rest
• Anti-inflamamtory +/- diazepam
• Early mobilisation
• Return to normal activity
• Education

2nd Line

• Physio
• Osteopath
• Chiropracter
• Psychologist
• Compliment therapy
• Surgery (only to reduce leg pain- no long term benefit)

Question 14

Cauda Equina Syndrome

Answer 14

EMERGENCY

Damage to the caudal equine, the nerve roots arising from the terminal end of the spinal cord

Question 15

Cauda Equina Syndrome Aetiology

Answer 15

Very large central disc prolapse which compresses all of the nerve roots of the caudal equina (L1-L5)

Question 16

Cauda Equina Consequences

Answer 16

Affected nerve roots control defection and urination

Prolonged compression can cause permanent nerve damage

Question 17

Cauda Equina Syndrome Signs

Answer 17

Bilateral leg pain
Saddle anaesthesia
Urinary retention
Faecal incontinence/ constipation

Question 18

Cauda Equina Syndrome Investigations

Answer 18

PR exa,

MRI

Question 19

Cauda Equina Syndrome Treatment

Answer 19

Treatment varies with cause

Question 20

Spinal Fractures Management

Answer 20

Urgent Treatment

• Immobilise
• X-ray
• Deal with other injuries

Question 21

Spinal Cord Injuries Aetiology (10)1

Answer 21

Swelling
Oedema
Iscaemia
Thrombosis of small vessels
Hypoxaemia
Hypotension
Stretching
Compression
Surgery
Infection

Question 22

Types of spinal cord injury and causes

Answer 22

Complete
- forced hyperextension

Incomplete

• Caused by vascular insult
• Brown-sequard
• Central cord injury
• Anterior cord injury

Question 23

Scoliosis

Answer 23

Lateral deviation of the spine

Question 24

Scoliosis Types (4)

Answer 24

Congenital
Early onset
Late onset
Secondary

Question 25

Secondary scoliosis

Answer 25

Neuromuscular problems
Tumours
Cerebral palsy
Spina bifida

Question 26

Mechanical Back Pain

Answer 26

Recurrent relapsing and remitting back pain with no neurological symptoms

Question 27

mechanical back pain aetiology (8)

Answer 27

Obesity
poor posture
Poor lifting technique
Lack of physical activity
Depression
Degenerative disc prolapse
Facet joint OA
Spondylosis

Question 28

Spondylosis

Answer 28

Intervertebral discs lose water content with age which causes less cushioning and secondary OA due to increased facet joint pressure

Question 29

Mechanical Back Pain Treatment

Answer 29

Analgesia

Physiotherapy

Question 30

Acute Disc Tear Aetiology

Answer 30

heavy lifting

Question 31

Acute Disc Tear Characteristics

Answer 31

Pain

• Worse when coughing
• Severe(periphery of disc is richly innervated so pain is severe)

Question 32

Acute Disc Tear treatment

Answer 32

Analgesia

Physiotherapy

Question 33

Spinal Stenosis

Answer 33

Narrowing of the spinal canal due to a bulging ligament flavour, osteophytes, bulging disc etc

Question 34

Spinal Stenosis Epidemiology

Answer 34

Around 60 years old

Question 35

Spinal Stenosis Presentation

Answer 35

Pain in legs when walking (claudication)

• Distance is inconsistent
• Burning pain
• less when walking uphill
• preserved pedal pulses

Question 36

Spinal stenosis treatment

Answer 36

Conservative measures

• Weight loss
• physiotherapy
• analgesia

Surgery if conservative measures fail or MRI evidence of stenosis

Question 37

Malignancy epidemiology

Answer 37

Older patients are at higher risk

Question 38

Malignancy characteristics

Answer 38

Pain

• Constant
• Unremitting
• Worse at night

Question 39

Malignancy investigations

Answer 39

Thorough history
CRP, FBC, U&E's
Bone biochemistry
Plasma protein electrophoresis
PSA in males
Blood culture
CXR
Bone scan
MRI