Back Pain and Sciatica

Question 1

what should you ask a patient about onset of their back pain when taking history?

Answer 1

was it sudden?

have you noticed trigger?

Question 2

how may patient describe character of back pain?

Answer 2

dull

stabbing

Question 3

location and radiation of back pain is an indicator for cause - true or false?

Answer 3

true
radiates to buttocks = muscular pain
radiates to knee = nerve pain

Question 4

after how many months would back pain be considered chronic?

Answer 4

> 3 months

Question 5

how should you ask about the intensity of back pain without using 1-10 scale?

Answer 5

ask about what tasks it prohibits them from doing that they could do previously eg climbing stairs

Question 6

what symptoms should you always ask about in patients with back pain?

Answer 6

urinary symptoms and faecal symptoms (eg incontinence of both)

Question 7

what factors can potentially aggravate back pain?

Answer 7

certain positions
coughing, sneezing (raises intrathecal pressure on nerve roots)
waking down stairs (due to walking on heel first)

Question 8

what factors can relieve a persons back pain?

Answer 8

certain positions ie lying and standing usually better than sitting
non-pharma methods eg physio and chiropractor
analgesia

Question 9

what symptoms should be asked about in systemic review to check for causes other than mechanical back pain?

Answer 9

fever
weight loss
abdominal pain 
cough/haemoptysis
dysuria / haematuria

Question 10

what parts of PMH should you ask about specifically when patient has back pain?

Answer 10

previous trauma
previous operations eg on spine
previous malignancy

Question 11

what parts of the social history are important when patients present with back pain?

Answer 11

occupation (type of work, level of activity)
smoking 
recreational drugs (eg steroids)

Question 12

back pain can be referred from elsewhere - true or false?

Answer 12

true - always check a patients back pain is not referred pain

Question 13

what are the main red flags of back pain?

Answer 13

pain at night or at rest
failure of pain to improve after 4-6 weeks of conservative therapy
motor or sensory deficits

Question 14

what red flags of back pain and other risk factors may indicate cancer?

Answer 14

> 50 years old
unintentional weight loss
previous history of cancer
night pain

Question 15

what symptoms and risk factors would indicate back pain is due to infection?

Answer 15

fever / chills 
recurrent infection 
immunosuppression 
IVDU
dental status 
foreign travel

Question 16

what symptoms and risk factors would make you consider that a patients back pain is due to fracture?

Answer 16

> 50 years old
osteoporosis (esp females)
trauma
chronic steroid use

Question 17

what symptoms and risk factors would indicate lower back pain is due to sciatica?

Answer 17

bilateral sciatica
urinary incontinence 
leg weakness
impaired anal tone 
loss of perianal sensation

Question 18

what signs and symptoms may indicate an AAA causing lower back pain?

Answer 18

> 60 years old
pulsating mass
pain at rest

Question 19

what other tests should be completed alongside a spinal examination?

Answer 19

straight leg test (testing hips)
test muscle strength
test sensation 
deep tendon reflexes 
standing on heels then toes (whilst supported)
lower limb assessment

Question 20

investigations are often not required in patients with lower back pain - true or false?

Answer 20

true - 70-90% dont require investigating as it will resolve with analgesia and activity

Question 21

who should we x-ray when they complain of back pain?

Answer 21

young men - check SI for ank spond

elderly - vertebral collapse, fracture, malignancy

Question 22

when is CT used to investigate back pain?

Answer 22

limited use unless red flags to look for bone pathology (tumour, infection, trauma)

useful if MRI contraindicated

Question 23

when is MRI used to investigate back pain?

Answer 23

visualise soft tissue
if suspicious of new fracture / microfractures
shows body oedema

if red flags use MRI first then CT

Question 24

what is a radionuclide bone scan used to investigate in back pain?

Answer 24

shows increased bone turnover (eg pagets, ank spond)

shows tumours and mets as these have increased cell turnover

Question 25

why is a PET scan used in back pain investigation?

Answer 25

increased uptake in areas of high turnover - closest modality we currently have to imaging areas of pain

Question 26

what are lab tests used for in context of back pain?

Answer 26

rule out malignancy and infection

Question 27

what non-pharmacological treatments are used in back pain?

Answer 27

explain/educate
reassurance most is self-limiting
advice on activity / exercise

Question 28

what simple analgesia is often used in back pain management?

Answer 28

NSAIDs (useful for MSK pain but unsuitable for many patients)
opioids for breakthrough pain

Question 29

what injections can provide relief in back pain?

Answer 29

facet joint injections

epidural blocks

Question 30

what complementary / alternative therapy is sometimes used in back pain?

Answer 30

acupuncture 
chiropractor 
osteopath 
massage 
physio

Question 31

when should you begin to investigate a patient with back pain?

Answer 31

if no improvement after 4-6 weeks of conservative management

Question 32

when should back pain be referred?

Answer 32

intractable pain
serious pathology suspected
neurological deficit

Question 33

what are the risk factors for mechanical back pain?

Answer 33

previous episode of back pain
heavy lifting / frequent bending
repetitive work
exposure to vibration (construction work)

Question 34

how can back pain be prevented?

Answer 34

education on lifting/turning with heavy objects
mental coping strategies for pain
smoking cessation

Question 35

other than mechanical back pain, what differentials could be causing a patients back pain?

Answer 35

root compression due to degenerative disease
sinister causes (tumour, TB)
compression outside spine (eg endometriosis)
no root compression (peripheral neuropathy)

Question 36

what is piriformis syndrome and what nerve does it affect?

Answer 36

condition where sciatic nerve runs within piriformis muscle = when muscle contracts, patient experiences sciatic pain

Question 37

sciatica is generally self-limiting, true or false?

Answer 37

true