Back Pain Flashcards
What percentage of the population are likely to be affected by back pain?
80%
What percentage of patients with back pain have sciatica?
5-10%
What percentage of the population suffer sciatica each year?
2%
What is meant by sciatica?
Pain arising in the back but predominantly radiates down the leg
What is non-specific low back pain?
Pain not due to anyspecificor underlying disease that can be found
No cancer, fracture, inflammation etc.
What is the trouble with non-specific back pain?
Must do many more investigations before finding causative condition
Many guidelines do not reach the stage of discovering cause
What is mechanical low back pain?
Painafter abnormal stress and strain on the vertebral column
e.g. Whiplash
What is nerve root pain?
Painradiating to the lower limbs with or without neuralgic symptoms
(Sciatica)
What are the causes of back pain?
Mechanical (90%) Tumour including myeloma Infection Spondyloarthropathy Pars interarticularis injury Compression fracture Visceral
What comprises mechanical stress?
Disc degeneration Disc herniation Annular tears Facet joint OA Instability
What are annular tears?
Little rips within the disc
Tears allow jelly to leak out to the outer margin of the discs
Chemicals of the jelly are irritant
In which tumour is there almost always back pain?
Myeloma
Often mistaken for mechanical back pain
Very important to diagnose early
What are the features of infection causing back pain?
Infection
More frequent if previous surgery
Increasingly common due to TB of the spine
What is Spondyloarthropathy?
Inflammatory joint disease
Falls under remit of rheumatologist
Treated aggressively with biologic agents with high rates of success
What is Pars interarticularis injury?
Bit between the facet joints
Can undergo stress fractures
Typical in those involved in dance (ballet), gymnastic or fast bowling
If they stop it heals nicely - but if left can cause serious problems
What are compression fractures?
Older age group with osteoporosis and ordinary activity can lead to a fracture e.g. washing up
Or major trauma
What is visceral back pain?
Pain that is coming from somewhere else in the body that makes you think you have back pain
e.g. aortic dissection, pancreatitis
What are indicators of sciatica?
Unilateral leg pain greater than low back pain
Pain radiating to foot or toes
Numbness and paraesthesia in the same distribution
Straight leg raising test induces more leg pain
Localised neurology—that is, limited to one nerve root
What is the NICE guidance for imaging back pain?
Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.
Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.
Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.
Why is imaging not that useful for back pain?
Not very helpful
Costs a lot of money
Takes a lot of time
What are the possible treatments for back pain?
Injections Exercise Corsets Traction Manipulation Acupuncture Ultrasound therapy Transcutaneous nerve stimulation Psychological therapy NSAIDS Paracetamol Weak opioids Opioids Radiofrequency denervation Epidural Spinal fusion Disc replacement
Why do people often stop taking pain killers?
Pain killers often do not work very well but the side effects are bad
What is the conservative treatment for back pain?
Analgesia (Paracetamol) Anti-inflammatory drugs Manipulation Acupuncture Massage Allow some time to pass
Bed rest does not result in faster recovery
Most patients get better spontaneously
What is the purpose of manipulation?
Move the muscles
Restore alignment
Why can acupuncture be considered?
Worth a try
Rarely does any harm
What is the aim of conservative treatment?
Most pain will resolve itself
These will help the patient feel more comfortable during the healing period
What are the red flag signs for lower back pain?
Weight loss
Fever
Night pain
Under 19 years
What is weight loss a sign of?
Cancer or Infection
What is needed when back pain if found in under 19s?
Urgent MRI
What are the red flags symptoms for sciatica?
Bowel or bladder dysfunction
Saddle anaesthesia
Profound neurological deficit
What are the features of spinal metastases?
Early diagnosis may not impact on prognosis
Risk of catastrophic fracture and paralysis
Onset of symptoms to referral median 3 months
What are the features of myeloma?
Early diagnosis will catch disease at a more easily treated stage
Mean delay in diagnosis - interquartile range 84 to 306 days
What are the features of spinal TB?
Early diagnosis is essential to effective treatment
Mean delay in diagnosis - 4 to 11 months
What are the features of Inflammatory arthropathy?
Early diagnosis for effective treatment with biologics
Investigate under 35 years after 3 months pain
What is the primary investigation for lower back pain?
MRI
What are secondary investigations for lower back pain?
Radiographs
CT
What are the features of radiographs?
Cheap
Readily available
Traditional
Moderate Radiation
Overlook most important diseases
Why might young people get osteoporosis?
Anorexia nervosa
What is important to note about scans?
They can miss lesions
Must use multiple imaging if unsure
What is osteoid osteoma?
Benign tiny tumour of bone that causes a massive reaction - oedema
How is osteoid osteoma cured?
Day case simple ablation procedure
Summarise the effectiveness of imaging for low back pain?
Radiographs have negligible value in the assessment of back pain
CT is an adjunct in a few cases
MRI is the workhorse
What is important to always remember with low back pain?
Low back pain is non-specific until you investigate
Cannot just dismiss as mechanical if persistent
In primary practice what is important to do with regards to low back pain?
Keep patient reasonably active within the bounds of pain
Not extended periods of back pain
What are the methods for treating nerve pain?
Root block
CT guided root block
