Back Pain & Sciatica Flashcards
What are the red flags for sinister causes of back pain? List a few.
Aged <20 or >55 Acute onset in elderly people Nocturnal pain Worse pain on being supine Abdominal mass Thoracic back pain Morning stiffness Neurological disturbance Current or recent infection
What are the most common causes of back pain in 15-30 year olds?
Prolapsed disc Trauma Fractures Ankylosing spondylitis Spondylolisthesis (a forward shift of one vertebra over another) Pregnancy
What are the most common causes of back pain in 30-50 year olds?
Prolapsed disc
Degenerative spinal disease
Malignancy
What are the most common causes of back pain in >50 years?
Degenerative spinal disease Osteoporotic vertebral collapse Paget's Malignancy Myeloma Spinal stenosis
What are the investigations for back pain?
FBC, ESR, CRP (myeloma, infection, tumour)
U&E, ALP (Paget’s)
Serum/urine electrophoresis (myeloma)
MRI: gold standard for cauda equina, disc prolapse, cancer, infection or inflammation
What is the management for back pain?
If any neurological deficits: neurosurgical referral
For non specific back pain: education and self management. Regular paracetamol, NSAIDs and or codeine. NSAIDs are first line.
Consider low dose amitryptiline or duloxetine if these fail.
Offer physiotherapy, acupuncture or an exercise programme if not improving
Do not routinely offer lumbar spine X-Ray
How does acute cauda equina compression present?
Alternating or bilateral root pain in legs
Perianal saddle paraesthesia
Loss of anal tone on PR
Bladder or bowel incontinence
How does acute cord compression present?
Bilateral pain
LMN signs at level of compression
UMN and sensory loss below
Sphincter disturbance
What is the immediate urgent treatment of spinal cord compression?
Laminectomy for disc protrusions
Radiotherapy for tumours
Decompression for abscesses
What are the causes of a spinal cord compression?
Bony metastasis
Large disc protrusion
Myeloma
Cord or paraspinal tumour
How does spinal stenosis present?
Gradual onset
Unilateral or bilateral leg pain, numbness, weakness, worse on walking.
Relieved by sitting down, leaning forward, and crouching down
Pain may be described as ‘aching’ or ‘crawling’
MRI to confirm diagnosis
Name three causes of lower back pain
Spinal stenosis
Ankylosing spondylitis
Peripheral arterial disease
What are the indications for MRI due to back pain?
‘Non specific back pain’ only if the results are likely to change the management.
To patients where malignancy, infection, fracture, cauda equina, or ankylosing spondylitis are suspected
What advice would you give to people with lower back pain?
Try to encourage self management
Stay physically active and exercise
What is the guideline for prescribing NSAIDs to patients?
When prescribing NSAIDs to patients >45 years, prescribe a PPI too
How does a prolapsed disc present?
Clear dermatomal leg pain associated with neurological deficits
Leg pain usually worse than back pain
Pain worse when sitting
How does a spinal epidural abscess present?
Fever
Back Pain
Focal neurological deficits
What is the pathophysiology of a spinal epidural abscess?
A collection of pus covered by a pyogenic membrane that is superficial to the dura mater. Bacteria enters from a different source.
Most common organism is Staphylococcus aureus
What are the investigations for a spinal epidural abscess?
Blood culture
Inflammatory markers, HIV, Hep B, Hep C
Infection screen
MRI whole spine
How does spinal metastases present?
Unrelenting lumbar back pain Thoracic or cervical back pain Worse with sneezing, coughing or straining Nocturnal Associated with tenderness
What abdominal pathologies could present with back pain?
Pancreatic cancer Cholecystitis AA Perforating ulcer Pyelonephritis
Where does shoulder pain radiate to?
Upper arm
Where does hip pain radiate to?
Anterior thigh
Knee
What are the nerve roots of the sciatic nerve?
L4, L5, S1-3
Made up of the tibial nerve and common fibular nerve
What is the definition of sciatica?
Irritation to the sciatic nerve of the spinal nerves that form it
What are the spinal causes of sciatica?
Related to spinal column Intervertebral disc herniation (poor posture, trauma, and strong rotational movement can cause this) Spinal stenosis Spondylolisthesis Tumours, cysts, abscesses
Herniation leads to an immune response to attack the nucleus pulposus and IL1 and IL6 and TNF attacks this leading to further sciatic nerve compression.
What are the non spinal causes of sciatica?
Piriformis syndrome (causes inflammation, compression ) Pregnancy
What are the symptoms and signs of sciatica?
Aching & sharp leg pain
Below the knee the pain follows dermatomal distribution
Could begin suddenly or gradually depending on the cause
Typically unilateral
Sometimes can be accompanied by numbness, weakness or loss of reflexes
How do you diagnose sciatica?
Lasegue’s sign (straight leg raise test)
-Patient lies flat and raises their straight leg, the pain will increase between 30-70 degrees if the test is positive
CT/MRI should be used
