Back Pain and Sciatica Flashcards
what is buttock pain likely to be
muscular
what is back pain going to below the knee likely to be
nerve- disc problem
what are the general red flags for back pain
general
- failure to improve after 4-6 of conservative treatment
- unrelenting night pain or pain at rest
- progressive motor or sensory deficit
what are the cancer red flags in back pain
cancer
- age > 50
- unintentional weight loss
- Hx of cancer
- pain at night and in recumbency
what are the infection back pain red flags
infection
- fever/ chills
- recent infection
- immunosuppression
- IV drug use
- dental status
- foreign travel
what are the cauda equina red flags
- Bilateral sciatica
- Urinary incontinence
- Leg weakness
- Absent anal tone
- Loss of perianal sensation
what are the red flags for fracture in back pain
- age > 50
- osteoporosis
- significant trauma
- chronic steroid use
what are the res flags for AAA in back pain
- age > 60
- abdominal pulsating mass
- pain at rest
what root levels:
hip flexion
L2,3
what root levels:
hip extension
L4,5
what root levels:
knee extension
L3,4
what root levels:
Knee flexion
L5,S1
what root levels:
ankle dorsiflexion
L4,5
what root levels:
ankle plantarflexion
S1,2
what root levels:
foot eversion
L5,S1
what root levels:
foot inversion
L4
what are the MRC muscle power grades
0- complete paralysis
1- flicker of contraction possible
2- movement possible if gravity eliminated
3- movement against gravity but not resistance
4- movement possible against some resistance
5- power normal
do you need to investigate all back pain
no 70-90% are innocent, resolve in a month with conservative Tx
when should you do an x ray
do not x ray routinely
except in
- young men at SI joint to exclude ank spon
- elderly to exclude vertebral fractures, collapse, malignancy
-for deformity correction surgeries
what are CT scans good for
bony pathology- trauma, tumours, infection)
- good for foreign bodies, implants
- spinal fusion planning
- if MRI contraindicated/ not available
- limited use in acute LBP unless red flags
what is MRI good for
red flags in back pain= MRI
neurological signs/ symptoms= MRI
- soft tissue (inc tumours and infection)
- some sequences good for new fractures
- bone oedema/ microfractures
what do radionucleotide scans show
increased bone turnover (tumours, pagets, fractures, osteomyelitis, ank spon, mets, osteoid osteoma)
what does a PET scan show
increased uptake in high turnover areas
when do you do lab tests in back pain
when red flags present
- malignancy (PSA, acid phosphate, monoclonal bands)
- infection
- metabolic causes (alk phos, Ca2+ etc)
what is the treatment for back pain
aim to relieve pain and find underlying cause
- explanation, reassurance, advice on activity and exercise, NO BED REST
- WHO pain ladder
- facet joint/ epidural injections for pain relief
- complementary and alternative mechanisms (acupuncture, chiropracture, osteopath, massages, PHYSIOTHERAPISTS)
what do you investigate back pain
no improvement in 4-6 weeks
any red flags
when do you refer back pain
- intractable pain
- serious pathology suspected or suggested on initial imaging
- neurological deficit
what are the risk factors for mechanical back pain
previous back pain
heavy lifting/ frequent bending
repetitive work with exposure to vibration
how do you prevent mechanical back pain
education- lifting, turning etc, mental coping strategies, stopping smoking
maintain physical activity
what are the differential for causes of sciatic back
- root compression by degenerative causes (bone spurs, canal stenosis, spondylolisthesis, facet arthropathy)
- root compression of sinister causes (tumour, fractures, TB)
- root compression of sinister causes (tumour, #, TB)
- root compression outside the spine (piriformis syndrome, endometriosis, pelvic disease, peroneal compression)
- no root compression (arachnoiditis, peripheral neuropathies)
what is piriformis syndrome
when the sciatic nerve goes through the piriformis muscle which can compress the nerve
is sciatic permanent
no generally self limiting
