Back Pain COPY Flashcards
What are some stats on the population and incidence of back pain?
49% to 70% of people will suffer low back pain
Most are better in a few days , 96% are better in six weeks
5% to 10% of patients with low back pain have sciatica
2% of the population suffer sciatica in one year
60% recover from sciatica in three months
70% recover from sciatica in 12 months
30% continue to have sciatica for over one year
What is sciatica?
Arises from the back
But predominantly pain radiating down the leg (as opposed to lower back pain)
This is referred pain
What are the different types of back pain and how are they defined?
Non-specific low back pain = pain not due to any specific or underlying disease that can be found e.g. not due to cancer, pinched nerve, inflammation etc.
Mechanical low back pain = pain after abnormal stress and strain on the vertebral column e.g. whiplash in car crash, lifting something heavy, etc.
Nerve root pain e.g. sciatica) - pain radiating to the lower limbs with or without neuralgic symptoms e.g. burning, loss of sensation in some patches, numbness, pins and needles, etc.
90% of lower back pain is mechanical. What are some examples of the causes of this?
Disc degeneration
Disc herniation
Annular tears - tears in the disc causes jelly structure to leak out and the chemicals of the jelly irritate surrounding structures
Facet joint OA = most common
Instability - only requires 1-2mm to cause pain
What conditions may be diagnosed primarily as mechanical back pain but ends up being more serious?
Tumour including myeloma
Infection = uncommon, except with operation in the PMH, although this is increasing due to increasing levels of TB in the spine
Spondyloarthropathy - inflammatory joint disease, referred to rheumatologist, treated vigorously with biologics for max success rate
Pars interarticularis injury - little bit of bone between the joint surfaces that can undergo a stress fracture esp. from repeated actions e.g. from sports, ballet, fast bowling, dance, etc. Heals quickly if person stops the cause (sport) but causes serious problems if they do not
Compression fracture = generally older age group due to osteoporosis, from a daily task; major trauma in younger population
Visceral - referred pain e.g. dissection of the aorta, pancreatitis etc.
What are some indicators for sciatica in the history and physical examination of a patient complaining of back pain?
Unilateral leg pain greater than low back pain
Pain radiating to foot or toes
Numbness and paraethesia in the same distribution
Straight leg raising test induces more leg pain - if leg is raised, it moves the nerve, so stress of raising the leg will cause tension signs
Localised neurology—that is, limited to one nerve root
What are the NICE guidelines for back pain imaging?
Do not routinely offer imaging in a non-specialist 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, that may not need imaging
Consider imaging in specialist settings of care (e.g. hospital, A&E, etc.) for people with low back pain with or without sciatica only if the result is likely to change management
What are the treatment options for back pain?
Treatment
Injections Exercise Corsets Traction Manipulation Acupuncture Ultrasound therapy Transcutaneous nerve stimulation Psychological therapy NSAIDS Paracetamol - not very effective in eliminating pain completely Weak opioids Opioids - addictive, taking these long term gives you a 2% mortality within the year Radiofrequency denervation Epidural Spinal fusion Disc replacement
What should be done for those with low back pain?
Conservative Treatment =
Analgesics on regular basis (paracetamol) - although does not eliminate pain, does ease the pain a little
Over-the-counter anti-inflammatory drugs e.g. ibuprofen
Acupuncture and Manipulation = essentially the same, movement of the muscle helps resolve the pain sometimes, and rarely causes harm
Massage = does not directly treat back pain, but helps loosen up muscle spasms
Allow some time to pass - most patients get better spontaneously
Bed rest does not result in faster recovery
What are the red flag signs for low back pain that require urgent investigations and treatment?
Urgent imaging if =
Weight loss - sign of cancer or infection
Fever - sign of infection
Night pain - may be a malignancy
Under 19 years
What is the issue with using red flag signs of low back pain for imaging referrals?
Insufficient evidence - i.e. no stats with what percentage of those with back pain and weight loss get a diagnosis of cancer
Therefore these are guidelines, not instructions
Patients without red flag symptoms may be referred for imaging
What are the red flag signs for leg pain that require urgent investigations and treatment?
Imaging and treatment straight away (for that day, waiting for 12hrs+ = permanent damage)
Bowel or bladder dysfunction
Saddle anaethesia
Profound neurological deficit
Signs of CES - Cauda Equina Syndrome
1 in 10 of these require surgery
Why is imaging not that useful for back pain and so is not just given to every patient with low back pain?
Not very helpful
Costs a lot of money
Takes a lot of time
May find something unrelated and not causing any symptoms, but may still need to look into that unnecessarily
What happens if you wait too long with red flag signs?
Metastases
- Early diagnosis may not impact on prognosis
- Risk of catastrophic fracture and paralysis
- Onset of symptoms to referral median 3 months
Inflammatory arthropathy
- Early diagnosis for effective treatment with biologics
- Investigate in anyone under 35 complaining of a 3 month history of pain
Myeloma
- Early diagnosis will catch disease at a more easily treated stage
- Mean delay in diagnosis of 84-306 days
TB of the spine
- Early diagnosis is essential to effective treatment
- Mean delay in diagnosis 4-11 months
Why do you not want to wait too long with imaging red flag symptoms?
Early diagnosis = more treatment options available
