Back Pain and Sciatica Flashcards
what should you ask a patient about onset of their back pain when taking history?
was it sudden?
have you noticed trigger?
how may patient describe character of back pain?
dull
stabbing
location and radiation of back pain is an indicator for cause - true or false?
true
radiates to buttocks = muscular pain
radiates to knee = nerve pain
after how many months would back pain be considered chronic?
> 3 months
how should you ask about the intensity of back pain without using 1-10 scale?
ask about what tasks it prohibits them from doing that they could do previously eg climbing stairs
what symptoms should you always ask about in patients with back pain?
urinary symptoms and faecal symptoms (eg incontinence of both)
what factors can potentially aggravate back pain?
certain positions
coughing, sneezing (raises intrathecal pressure on nerve roots)
waking down stairs (due to walking on heel first)
what factors can relieve a persons back pain?
certain positions ie lying and standing usually better than sitting
non-pharma methods eg physio and chiropractor
analgesia
what symptoms should be asked about in systemic review to check for causes other than mechanical back pain?
fever weight loss abdominal pain cough/haemoptysis dysuria / haematuria
what parts of PMH should you ask about specifically when patient has back pain?
previous trauma
previous operations eg on spine
previous malignancy
what parts of the social history are important when patients present with back pain?
occupation (type of work, level of activity) smoking recreational drugs (eg steroids)
back pain can be referred from elsewhere - true or false?
true - always check a patients back pain is not referred pain
what are the main red flags of back pain?
pain at night or at rest
failure of pain to improve after 4-6 weeks of conservative therapy
motor or sensory deficits
what red flags of back pain and other risk factors may indicate cancer?
> 50 years old
unintentional weight loss
previous history of cancer
night pain
what symptoms and risk factors would indicate back pain is due to infection?
fever / chills recurrent infection immunosuppression IVDU dental status foreign travel
what symptoms and risk factors would make you consider that a patients back pain is due to fracture?
> 50 years old
osteoporosis (esp females)
trauma
chronic steroid use
what symptoms and risk factors would indicate lower back pain is due to sciatica?
bilateral sciatica urinary incontinence leg weakness impaired anal tone loss of perianal sensation
what signs and symptoms may indicate an AAA causing lower back pain?
> 60 years old
pulsating mass
pain at rest
what other tests should be completed alongside a spinal examination?
straight leg test (testing hips) test muscle strength test sensation deep tendon reflexes standing on heels then toes (whilst supported) lower limb assessment
investigations are often not required in patients with lower back pain - true or false?
true - 70-90% dont require investigating as it will resolve with analgesia and activity
who should we x-ray when they complain of back pain?
young men - check SI for ank spond
elderly - vertebral collapse, fracture, malignancy
when is CT used to investigate back pain?
limited use unless red flags to look for bone pathology (tumour, infection, trauma)
useful if MRI contraindicated
when is MRI used to investigate back pain?
visualise soft tissue
if suspicious of new fracture / microfractures
shows body oedema
if red flags use MRI first then CT
what is a radionuclide bone scan used to investigate in back pain?
shows increased bone turnover (eg pagets, ank spond)
shows tumours and mets as these have increased cell turnover
why is a PET scan used in back pain investigation?
increased uptake in areas of high turnover - closest modality we currently have to imaging areas of pain
what are lab tests used for in context of back pain?
rule out malignancy and infection
what non-pharmacological treatments are used in back pain?
explain/educate
reassurance most is self-limiting
advice on activity / exercise
what simple analgesia is often used in back pain management?
NSAIDs (useful for MSK pain but unsuitable for many patients)
opioids for breakthrough pain
what injections can provide relief in back pain?
facet joint injections
epidural blocks
what complementary / alternative therapy is sometimes used in back pain?
acupuncture chiropractor osteopath massage physio
when should you begin to investigate a patient with back pain?
if no improvement after 4-6 weeks of conservative management
when should back pain be referred?
intractable pain
serious pathology suspected
neurological deficit
what are the risk factors for mechanical back pain?
previous episode of back pain
heavy lifting / frequent bending
repetitive work
exposure to vibration (construction work)
how can back pain be prevented?
education on lifting/turning with heavy objects
mental coping strategies for pain
smoking cessation
other than mechanical back pain, what differentials could be causing a patients back pain?
root compression due to degenerative disease
sinister causes (tumour, TB)
compression outside spine (eg endometriosis)
no root compression (peripheral neuropathy)
what is piriformis syndrome and what nerve does it affect?
condition where sciatic nerve runs within piriformis muscle = when muscle contracts, patient experiences sciatic pain
sciatica is generally self-limiting, true or false?
true
