Back Pain & Sciatica Flashcards
List 3 general red flags in back pain
Failure to improve after 4-6 weeks conservative therapy,
Night pain/pain at rest
Progressive motor/sensory deficit
List 5 cancer red flags of back pain
Age >50, Unintended weight loss, Hx cancer, Night pain Pain lying down
List 6 red flags for infection in back pain
Fever/chills, Recent infection, Immunosuppression, IV drug use, Dental status, Foreign travel
List 4 red flags for fracture in back pain
Age >50,
osteoporosis,
Significant trauma,
Chronic steroid use
List 5 red flags for Cauda Equina Syndrome in back pain
Bilateral sciatica, Urinary incontinence, Decreased anal tone, Loss of perianal sensation, Leg weakness (not always)
List 3 red flags for AAA in back pain
Age >60,
abdo pulsating mass,
Pain at rest
What does the Straight leg raise test assess?
Hip is flexed until pain is noted which stretches hamstrings and sciatic nerve. Patients with herniated disc often experience back pain radiating to lower leg
Weak leg flexion is problem with what nerve roots
L2,3
Weak leg extension is problem with what nerve roots
L4,5
Weak knee extension is problem with what nerve roots
L3,4
Weak knee flexion is problem with what nerve roots
L5,S1
Weak ankle dorsiflexion is problem with what nerve roots
L4,5
Weak ankle plantar flexion is problem with what nerve roots
S1,2
Weak ankle inversion is problem with what nerve roots
L4
Weak ankle eversion is problem with what nerve roots
L5,S1
MRC is used to grade muscle power. Outline meaning of Grade 0-5
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
Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for L4 nerve root problem
Pain: felt along outside of leg and down front of knee and shine Numbness: felt on and above knee Motor weakness: quads extension Screening exam: squat and rise Reflexes: knee jerk diminished
Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for L5 nerve root problem
Pain: bum and then down along outer edge of whole leg
Numbness: outer calf and side of leg
Motor weakness: dorsiflexion of great toe and foot
Screening exam: heel walking
Reflexes: none reliable
Outline the common presentation of pain, numbness, motor weakness, screening exam and reflexes for S1 nerve root problem
Pain: bum and then down along middle of the back of the whole leg
Numbness: back of calf and bottom of foot
Motor weakness: plantar flexion of great toe and foot
Screening exam: walking on toes
Reflexes: ankle jerk diminished
Triceps reflexes tests what nerve roots?
C7,C8
Biceps reflexes tests what nerve roots?
C5, C6
Patellar reflexes tests what nerve roots?
L2, L3, L4
Achilles reflexes tests what nerve roots
S1
70-90% of LBP will resolve within a month. True/false?
True
X-rays are not very useful for back pain as do not show soft tissue. What are two exceptions where x-rays should be used for back pain?
Young men: SI-joint to exclude ank spond
Elderly: to exclude vertebral collapse, fractures, malignancy
What are EOS scans and what are they used for?
EOS are full spinal xrays with 10% of femur, useful for deformity and surgical planning
What are CTs useful for and what are they not useful for?
Show bony pathology, foreign bodies, implants, spinal fusion planning and if MRI contra-indicated.
Not very useful in acute LBP with no red flags
Gold standard for lower back pain and why?
MRI - good for soft tissue and bone oedema and microfractures
What are two presentations you should definitely investigate MRI?
Red flags or neurological signs/symptoms
What are radionuclide bone scans useful for? (4)
Increased bone turnover (fractures, osteomyelitis, Paget’s, ank spond),
Metastases,
Tumours, osteoid osteoma
Use of SPECT and PET scan for LBP?
Increased uptake in high turnover areas e.g. infection, malignancy
When are laboratory tests indicated?
Any red flags, malignancy, infection, metabolic causes
List 3 malignancy markers for LBP and what they test for
PSA and acid phosphatase - prostate cancer
Monoclonal bands - paraneoplastic syndrome
List 4 metabolic lab tests for LBP?
Alk phos, Ca2+ (e.g. bony mets), PO4, HLA B-27
What medication is good for relieving spasm?
Diazepam
Pharmacological conservative treatment for LBP?
NSAIDS, opiates, gabapentin, TCAs, injections + physio
What is the most effective prevention of back pain?
Physical activity
What is management plan for sciatica?
Initially conservative unless red flags, may be for surgical intervention.
Conservative because usually body resorbs disc material from disc bulge within 3 months
What are 4 potential differentials for sciatica that are caused by root compression outside the spine?
Piriformis syndrome,
Endometriosis,
PID,
Peroneal compression
What are 4 potential differentials for radiculopathy symptoms that is not caused by root compression?
Arachnoiditis e.g. from previous haemorrhage, peripheral neuropathies, IIH can cause cervical compression symptoms, SI joint dysfunction
