Back pain red flags

Question 1

What are the ‘features’ red flags for back pain?

Answer 1

Previous malignancy
Aged  50 with NEW onset
Unexplained weight loss
Previous longstanding steroid use
Recent serious illness
Recent significant infection

Question 2

What are the ‘signs’ red flags for back pain?

Answer 2

Saddle anaesthesia
Reduced anal tone
Hip or Knee weakness
Generalised neurological deficits
Progressive spinal deformity
Urinary retention

Question 3

What are the ‘symptoms’ red flags for back pain?

Answer 3

Non mechanical pain
Thoracic pain
Fever/Rigors
General malaise
Urinary retention

Question 4

What are the signs of cord compression?

Answer 4

Back pain
Leg weakness
Limb numbness
Ataxia
Urinary retention
Hyper reflexia
Extensor plantaris
Clonus

Question 5

What are the signs of Cauda Equina?

Answer 5

Bilateral leg pain
Back pain
Urinary retention
Perianal sensory loss
Erectile dysfunction
Reduced anal tone

Question 6

What investigations should be done if red flags are present?

Answer 6

Myeloma screen
CRP, FBC, U&Es, Ca2+
X-ray
Consider MRI

Question 7

What is the WHO analgesic ladder?

Answer 7

Non opioids eg Paracetamol +/- NSAIDs
Weak opioids eg codeine
Strong opioid eg morphine
Can add adjuvants at each level eg Amitriptyline or corticosteroids

Question 8

What are the yellow flags for back pain?

Answer 8

A - Attitude towards the current problem
B - Beliefs, faulty ones can lead to catastrophisation
C - Compensation, are they awaiting it?
D - Diagnosis and misunderstanding of it
E - Emotions, ongoing issues increase risks
F - Family and support
W - Work, relationship with it

Question 9

Why are yellow flags useful?

Answer 9

Help to identify patients who are more likely to develop chronic back pain

Question 10

Give an example of a condition that can cause inflammatory back pain

Answer 10

Ankylosing Spondylitis
Psoriatic arthritis
General manifestation of Inflammatory bowel disease
Infective/reactive arthritis

Question 11

What are the symptoms of spinal inflammation?

Answer 11

Back pain associated with prolonged early morning stiffness
Improvement of symptoms with exercise
Strong FH
Associated Uveitis

Question 12

What investigations are needed in a patient with suspected spinal inflammation?

Answer 12

MRI (Not much would be seen on X-ray)

Can do CRP if suspecting infective cause

Question 13

What is the treatment for patients with spinal inflammation?

Answer 13

Refer to Rheumatologist
Physiotherapy
NSAIDs

Question 14

What is Sciatica?

Answer 14

Pain due to compression of nerve roots L4, L5, S1, S2, S3

Question 15

What type of pain is felt in Sciatica?

Answer 15

A sharp shooting pain

Question 16

What is the most common cause of Sciatica?

Answer 16

Intervertebral disc herniation

Question 17

What is the treatment of Sciatica?

Answer 17

Usually resolves within 6 weeks
Analgesia
Physiotherapy
Hot/Cold compression packs
*If conservative treatment doesn't work, can do spinal injections of steroid/local anaesthetic or surgery)

Question 18

How is Sciatica diagnosed?

Answer 18

Usually clinically based on history and examination
Ensure red flags are addressed
Can do bloods/CT/MRI if serious causes suspected