Back pain Flashcards
What are the 3 clinical classification of lower back pain ?
0 simple back pain / non -specific (Mechanical ? ) 95% - main type
0 Back pain - with nerve root pain - 4 % of pop
0 Serous spinal pathology - 1 % of pop
What is mechanical back pain ?
Pain originates from joints , bones or soft tissues in and around spine.
considered non -specific MSK pain - strained muscles , ligaments in back
DIAGNOSIS -
0 no specific cause found
o unilateral dull pain
o may radiate to buttocks but not beyond knee ( this more suggestive of sciatica )
o patient is systemically well
0 Typically caused by :
1. heavy
lifting
2. poor
posture
3. incorrect
bending
etc.
4. poorly
designed
seating
0 Pain linked to :
o position - better or worse in certain positions
o activity - worse with physical activity - especially in acute phase - first 3 months.
- Usually started to get better within a few weeks.
o X -rays of back not routinely done for non -s pecific back pain
people low back pain - always exclude sciatica , inflammatory features & serious spinal pathology.
1st apponitment - X - ray not offered , physiotherapy , manual therapy - for non -specific pain.
after one week - if no better - physio / manual can be offered.
- if inflammatory component - refer to rheumotology - after ESR , CRP investigation.
Categories of back pain - not clinical classifications ?
0 Degenerative
0 Mechanical
0 Infections
0 cancer
0 Inflammatory disorder - ankylosing sponlitis ?
0 Spinal epidural hematoma
Red flags - things to look out for - with lower back pain - TUNA FISH
T U N A F I S H
T - Trauma
U - unexplained weight loss - suggestive of possible cancer
N - Neurological symptoms -
o sensory loss,
o pain
o weakness in legs
o saddle anesthesia ( loss of sensation in the perineum(btw anus & vulva/scrotum, buttocks, groin area )
o bowel, bladder, sexual dysfunction
( LAST 3 - indicative of Cauda Equina - surgical emergency - ASAP MRI.
A - Age - over 50 - increased risk of cancer
F - Fever - possible infection ?
I - Infection
o Fever
o intravascular drug use
o immunocompromised -
HIV ,
immunosuppressant use
o UTI
o TB
S - Steroid use - secondary osteoporosis
H - History of cancer
particularly - prostate,
breast, lung & kidney
CANCER
SPINAL FRACTURE - STRUCTURAL DEFORMITY
GAIT DISTURBANCE
o tripping over -
L5 damage due
to weakness of
extensor hallicus
longus - bizarre
gait pattern.
o If they limp -
look at hip and
rule out hip
issue
o Ataxia - group
of disorders -
disturbance in
balance , co-
ordination &
speech - upper
neurone ?
- Systemically unwell
Treatment of non specific MSK pain ?
Increase mobility - important not to be immobile ( will make it worse )
- apply heat or cold
- massage
- physical therapy
- Chiropractor
Medication -
NSAIDS
o e.g ibuprofen or Naproxen - first
line - lowest dose possible
* offer gastroprotection with NSAID use.
NSAID contraindiacted , ineffective - not tolerated
o codeine with/or without paracetamol .
( take into account risk of opiod dependence , side effect - constipation )
0 Opiods not use for chronic pain.
PARACETAMOL IS NOT GOOD ENOUGH ALONE.
0 Muscle spasm present - consider short course of benzodiazepine - e.g diazepam - 5 days etc.
(Muscle relaxants e.g Cyclobenzapine
Tizanidine) -NOT MENTIONED IN NICE GUIDELINES - OSMOSIS
Usually resolved within 2 -3 weeks
( if not may have a specific cause )
Safety net - if not better within 3 -4 weeks seek follow up.
,
Causes of mechanical pain ?
Disc Herniation
- risk in
spondylosis
can happen
in healthy -
who lift heavy
object ro
trauma
- cause Lumbarsacral radioculopathy / Sciatica - due to irritation or compression of nerve root.
o shooting pain - down back below knee.- unilateral ( posterior longitudinal ligament located - posteriorly to spine -------------------> nucleus pulposus - will herniate posteriolaterally as a result compressing / irritation the nerve root on that side ( not both ) - so unilateral symptoms.
compression of nerve root below e.g :
o L3 -L4 IV DISC HERNIATION compression of L4 NR
test
squat & rise
o L4 -L5 IV DISC HERNIATION compression of L5 NR
test - heal walk
o L5 -S1 IV DISC HERNIATION compression of S1 NR
test - toe walk
positive test - indicate herniation
Straight leg raise test — patient lies down – one leg raised unitl they complain of pain( shooting pain down leg)- (btw 30 -70 degrees )positive test = radiculopathy
- should be followed up by Lumbar X ray ( shows loss of disc height - degeneration )
however should be followed by Lumbar MRI for disc herniation.
TREATMENT
ACUTE
- NSAIDS
- PHYSICAL THERAPY
- CHIROPRACTER
SEVERE
- surgery may be needed
Infection - lower back pain ?
CAUSES
- vertebral osteomyelitisSYMPTOMS
- Pain - pinpint & well localised
- Fever
- pain
- Spinal epidural abscess
SYMPTOMS
- back pain
- fever
- neurological symptoms
High index of suspection needed - as not all 3 symptoms always how up.
CAUSATIVE ORGANISMS
- S. aureus
- Streptococci
- enteric bacilli
-Pseudomonas aeruginosa - common IV drug users - mycobacterium TB - if causes osteomyeltits - called pott’s disease
SPREAD
o Haematogenous- pathogen enters blood from distant site of infection ———-infects the vetebrae
almost always leads to discitis (infected disc)
discitis —.> infection can spread from disc to epidural space causing ———> spinal epidural abscess (SEA)
SEA - can also happen on its own.
(infection in epidural space - btw veterbrae & membrane lining spinal cord
- can grow big compress adjacent nerve root or spinal cord ———-> neurological symptoms.
o directly innoculated into veterbrae during trauma/ surgery
RISK FACTORS FOR BOTH
- UTI
- immunosupression e.g chronic steroid use & HIV
- IV drug use
- endocarditis - inflammation of endocardium - inner lining of heart.
- indwelling devices e.g central venous line
- diabetes
TEST -
0 CRP - C reactive protein ( produced by liver in response to inflammation) - indicates success of treatment - rises & falls quickly
& ESR ( erythrocyte sedimentation rate - not as commonly used - CRP used instead )
0 FBC - check for leukocytosis
( CBC - complete BC - another name)
blood & urine cultures
VO - Biopsy ( find CO)
imaging
MRI better than x ray
vertebral osteomyelitis + discitis - oedema of vertebral body & destruction of intervertebral space.
abcess - fluid filled sac - appears brighter with contrast.
TREATMENT
0 antibiotics
0 surgical decompression & drainage - for abscess with neurological deficits - most be done o prevent permanent paralysis
- if now deficit - sample of abscess taken- then antibiotic tailored to result.
VO - caused TB - potts disease - treated with R I P E regimine
R - rifampin
I - Isoniazid
F- Pyrazinamide
E- ethambutol
for 2 months
then R & I for the rest of the 9 -12 months
slowly progressing infection - does not cause symptoms unitl extensive involvement e.g abcesses - extensive spread
( spinal debridement - may be needed- removal of infected tissue from spine )
Spinal epidural haemotoma
0 Bleeding in epidural space
CAUSES
- Disc herniation
- recent surgery
- Trauma
- bleeding disorder / anti- coagulation therapy
SEVERE PAIN & well localized
o can compress adjacent nerve root & spinal cord
TEST
CBC - thrombocytopenia
- PT - prothrombin time( asses for coagulation problem ) .
DIAGNOSIS
MRI - sac of blood
o can extend across multiple spinal levels - get MRI of entire spine
TREATMENT
0 Surgical decompression - as soon as possible
0 problem with coagulation —> give fresh frozen plasma
Vetebral compression fractures – lower back pain
Imaging - X - ray , Ct , MRI (MRI - can distinguish btw acute & chronic VCF )
bone density study should be look at.
TREATMENT
NSAIDS
Biphosphonates - management of osteoporosis symptoms.
Cancer - Lower back pain ?
metastatic - cancer has spread from elsewhere to epidural space , veterbral marrow
common cancers that spread to spine : o Prostate o Breast o Kidney o Lungs
SYMPTOMS
o pain o Fever o night sweats o focal neurological symptoms o unexplained weight loss o not an improvement after 4-6 weeks of conservative management.
PAIN PATTERN
o constant o worse at night o not better with rest o localized spinal tenderness
IMAGING
- MRI - to check for metastases
SUSPECT WHEN :
all of the above - others also :
o thoracic pain
What is Cauda equina syndrome ?
Compression of cauda equina - compression of lumbar & sacral nerve rots after spinal cord ends.
SYMPTOMS
0 unilateral, or bilateral asymmetric sensory loss,
0 pain or weakness in the extremities,
0 loss of reflexes.
sudden unexplained bilateral lower-extremity weakness
THESE DIFFERIATE IT FROM LUMBARSACRAL RADICULOPATHY
0 saddle anesthesia
Bilateral sciatica.
0 bowel, bladder, or sexual dysfunction.
- urinary hesitancy
- urinary retention followed by overflow urinary incontinence
diagnosis - bladder ultrasound ( see how much urine left in bladder after they relieve themselves -PVR - Post- void residual)
PVR -
normal - below 30 ml
above 100 ml - sig neurological compromise
- Fecal retention ---> followed by overfow fecal incontinence
diagnosed by digital rectal exam
- diminished sphincter tone
male - erectile dysfunction.
TREATMENT
Surgery needed within 8 hours - to prevent permanent incontinence ( bladder stretches too much - never goes back ) - MUST NOT MISS - emergency MRI needed.
- WHEN PERSON COMES IN WITH BACK PAIN - make sure they can pass urine - if patient sent home - safety net e.g if you develop urinary hesitancy , saddle etc - come back )
What is Conus Medullaris syndrome ?
Damage to Conus medullaris - most distal bulbous part of spinal cord.
similar to Cauda equina:
o saddle anesthesia
o bowel , bladder & sexual dusfunction.
Difference :
bilateral & symmetrical pattern
o urinary & fecal incontinence - early syndrome.
compression of this area - can damage corticospinal tract - upper motor neurone signs below level of lesion
- Brisk , hyperactive reflexes
- spasicity
- extensor
plantar
response /
babinski
reflex
MANAGEMENT
- emergency MRI
- surgical decompression
- if cancer is the cause - IV corticosteriods.
spinal radiation
Inflammatory causes of back pain ?
Ankylosing spondylitis
commonly affects young males
- pain in spine , sacroiliac joint , entheses
PAIN PATTERN o gradual onset o improves with exercise o morning stiffness o not improve with rest.
EXTRA - ARTICULAR MANIFESTATIONS - ( means outiside of or other than a joint. -systemic
o uvetis
o Psoriasis
o Aortic root
dilation – increase risk of aortic dissection.
CBC / FBC - might show microcytic hypochromic anaemia -
CRP , ESR - maybe elevated - indicate inflammation
o positive for HLA B27 - almost all
IMAGING
X - ray , MRI of sacral iliiac joints.
see :
erosion
sclerosis
narrowing of joint space ( if they fuse - ankylosis )
- Bamboo spine - vertebrae abnormally connected together
TREATMENT
o anti-inflammatory E.G sulfasalazine
o tumor necrosis alpha inhibitors e.g. infliximab.
Possible causes of back pain - not linked to spine / vertebrae ?
AAA - abnominal aortic aneurysm
vague back , flank pain
Pulsatile abdnominal mass
- person may become hypotensve due to blood loss
DIAGNOSIS
- abdominal ultrasound.
0 retroperitoneal hemorrhage, can develop :
- people on anticoagulation therapy
- had cannulation of the femoral artery during a cardiac catheterization procedure
lead to bilateral flank hematomas, - Grey-Turner sign.
0 aortic dissection
0 pyelonephritis,
0 renal colic
0 pancreatitis
0 pelvic inflammatory disease
0 endometriosis,
0 prostatitis.
Degenerative back pain - lower back pain ?
Degenerative - age related wear and tear
o Spondylosis (
IV discs &
facets joint -
gradually
degenerate -
osteophytes (
bone lumps -
can grow ) -
compress
adjacent
nerve roots -
causing
radicular pain
/
radiculopathy
------ can also
narrow
intervetebral
foramen -
lumbar spinal
cord stenosis
edema & swelling
( radiculopathy & lumbar spine stenosis - code - R & LSS)
o Spondylolisthesis - vertebral body slips over body below it.
CAUSES
1. FACET ----->
FORWARD (
osteoarthritis
of facte joint -
anterior slip )
2.
degenerative
disc disease
DISC
DISEASE -------
------>
DORSAL
( posterior slip
)
cause R & LSS
Diagnosis
MRI - pick up slipped disc , osteophytes , degeneration of IV disc
TREATMENT
- Pain management
- physcial therapy
- Surgery
Causes of Lumbarsacral radiculopathy - Sciatica ?
Disc Herniation - most common
0 Spinal stenosis
0 Spondylolisthesis
Signs of Sciatica ?
PAIN PATTERN
0 unilateral leg pain - radiates below knee to foot & toes
(Leg pain worse than back pain if present )
0 In a dermatome - single nerve root compression
- Numbness
- paraesthesia( tingling)
- muscle weakness
- loss of tendon reflex
0 Straight leg test - positive - worsening of pain felt with raising of straight leg - more severe compression symptoms .
0 Extensor plantar response - lateral part of sole ( feet ) stimulated ——> toes extend and fan outwards - suggest upper motor neurone
lesion.
rule out red flag symptoms - cauda equina etc.
BEWARE - if symptoms of sciatica - examine hip & knee - exclude disorders of the hip & knee - similar symptoms
o referred pain - hip
osteoarthritis
o piriformis syndrome
- piriformis
compresses /.
irritates sciatic nerve-
covers sciatic nerve )
o Aspectic necrosis of
femoral head.
o Trochanteric Bursitis
- inflammation /
swelling of bursa (
fluid filled sacs near
joints )
o non spinal causes of
back pain
o spinal claudication
o Myelopathy - severe
spinal
cord compression.
decompression
surgery needed.
o Sacrolitis.
&
No red flags - same as non specific back pain
NSAID use
gastroprotection
DONT USE BENZODIAZEPINES WITH SCIATICA - used in non specific pain
- don’t use opioids , gabapentiniods , benzodiazepines
( if someone is already taking them discuss risks of continued use - discuss whether to continue - possible withdrawal symptoms. - if not improvement or worsens within 1-2 weeks - follow up appointment
HIGH RISK OF POOR OUTCOME
o group exercise program
o physiotherapist referral - manual therapy
o promote & facilitate return to normal activities in daily living & work.
o exercise with/or without manual therapy
o cognitive behavioural therapy - if psychosocial barriers to recovery e.g incorrect ideas on what will make them better - e,g staying still & not doing anything will make the pain better.
Referred pain - lower back pain .
If pain in several dermatomes - likely to be referred pain not radicular ?
Difference btw Cauda equina
& Conus medullaris ?
Conus medularis - most bulbous distal part of the spinal cord
Cauda equina - collection of nerves roots at the distal end of spinal cord - horse tail appearance
What is Lumbar spinal stenosis ?
narrowing of :
o central canal ( where spinal cord is located 0
o lateral recess - where nerve root exits central canal.
o neural foramen - foramen btw to spinal veterbrae,
CAUSES
0 spondylosis,
Positional pain - in terms of lumbar spinal stenosis pain caused by spondylosis-
neurogenic claudicaction / pseudoclaudiaction -
o neurogenic - arising in nervous system
o claudication - leg pain , heaviness, weakness wih walking
(pain induced by positions that extend spine e.g waking , standing erect - spinal canal , formina narrow on extension
relieve by positions that flex spine - sitting , leaning forward , lying down. ) - could ride a bike without pain )
0 spondylolisthesis,
0 trauma,
0 Paget disease of the bone - disruption to normal cycle of renewal of bone ( new bone replaces old bone ) - bones become weak or deformed . Normally affects: o Pelvis o spine o skull
Symptoms
o constant , dull bone pain
o joint pain , stiffness , swelling
o shooting pain - travels along body - numbness & tingling.
TREATMENT
- Biphosphonates
- risendronate
- Zoledronate
- pamidronate
- pain relief - para , ibu
0 achondroplasia.
PAIN PATTERN - LSS
- bilateral - as central stenosis - affect both sides
- not follow dermatome pattern
TREATMENT - o Physical therapy o NSAIDS o - if above does not work - Steroids o Surgery - surgical laminectomy - removal of all lamina of veterbrae - creates space
surgical laminotomy - part of lamina removed
What is vascular claudication ?
Vascular - BV / blood
Claudication - leg pain
pain in the legs as a result of too little blood flow to this area.
CAUSES
- usually peripheral artery disease - arteries supplying legs / (limbs )narrow - usually bcc of atherosclerosis.
Risk Factors for Chronicity
Previous history LBP
Total work loss (due to LBP) in last 12 months
Radiating leg pain
Reduced SLR
Signs of root involvement
Reduced trunk muscle strength
Poor physical fitness
Heavy smoking
Self- rated poor health
Psychological distress
Depressive symptoms
Disproportionate illness behaviour
Low job satisfaction
Personal problems
Medico-leqal proceedings
What is Carpal tunnel syndrome ?
Carpal tunnel - borders - roof ( Flexor Retinaculum , concave / floor surface - carpal bones.
Pressure on a nerve (median nerve ) in the wrist due carpel tunnel swelling and squeezing down.
SYMPTOMS
o Tingling ( pins & needles ) , numbness , pain in your heads and fingers. o Weak thumb - difficulty gripping
symptoms come and go - usually worse at night.
TREATMENT
0 self management - wrist splint in neutral position
(if they go to GP & the the splint helped - GP can offer steroid injection )
- avoid repetitive movements
- adaptation at workplace ( special mouse , keyboard )
0 Steroid injection - bring down swelling around median nerve - easing symptoms.
( CTS can come back after injection. )
0 Carpal Tunnel Syndrome - if CTS is getting worse & other treatments not worked
- usually cures
CTS. - Carpal tunnel cut - to stop compression on nerve
RISK FACTORS
0 overweight
0 pregnant
hobbies / Work - repeatedly bend your wrist or grip hard, e.g using vibrating tools
another illness arthritis, diabetes
0 parent, sibling with CTS
0 previously injured your wrist
( Linked to hormones - causes - The oral contraceptive pill Hypothyroidism Rheumatoid arthritis Pregnancy Cardiac failure )
TEST
0 positive Tinel’s sign - lightly tap/ percuss over median / affected nerve - - if irritated nerve- tingling sensation occurs radiates outwards in median / affected nerve distribution.
Phalen’s sign - mauever - wrist flexed upside down 90 degrees (upside down T )
Positive - ellicit symptoms in median nerve distribution.
- nerve conduction studies can be used to confirm diagnosis ( e.g measures how fast electrical impulse moves through nerve - uses electrodes - as measures disatance and time - calculates speed )
