Back Pain & Sciatica

Question 1

What are the red flags for sinister causes of back pain? List a few.

Answer 1

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

Question 2

What are the most common causes of back pain in 15-30 year olds?

Answer 2

Prolapsed disc
Trauma
Fractures
Ankylosing spondylitis 
Spondylolisthesis (a forward shift of one vertebra over another)
Pregnancy

Question 3

What are the most common causes of back pain in 30-50 year olds?

Answer 3

Prolapsed disc
Degenerative spinal disease
Malignancy

Question 4

What are the most common causes of back pain in >50 years?

Answer 4

Degenerative spinal disease
Osteoporotic vertebral collapse
Paget's
Malignancy
Myeloma 
Spinal stenosis

Question 5

What are the investigations for back pain?

Answer 5

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

Question 6

What is the management for back pain?

Answer 6

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

Question 7

How does acute cauda equina compression present?

Answer 7

Alternating or bilateral root pain in legs
Perianal saddle paraesthesia
Loss of anal tone on PR
Bladder or bowel incontinence

Question 8

How does acute cord compression present?

Answer 8

Bilateral pain
LMN signs at level of compression
UMN and sensory loss below
Sphincter disturbance

Question 9

What is the immediate urgent treatment of spinal cord compression?

Answer 9

Laminectomy for disc protrusions
Radiotherapy for tumours
Decompression for abscesses

Question 10

What are the causes of a spinal cord compression?

Answer 10

Bony metastasis
Large disc protrusion
Myeloma
Cord or paraspinal tumour

Question 11

How does spinal stenosis present?

Answer 11

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

Question 12

Name three causes of lower back pain

Answer 12

Spinal stenosis
Ankylosing spondylitis
Peripheral arterial disease

Question 13

What are the indications for MRI due to back pain?

Answer 13

‘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

Question 14

What advice would you give to people with lower back pain?

Answer 14

Try to encourage self management

Stay physically active and exercise

Question 15

What is the guideline for prescribing NSAIDs to patients?

Answer 15

When prescribing NSAIDs to patients >45 years, prescribe a PPI too

Question 16

How does a prolapsed disc present?

Answer 16

Clear dermatomal leg pain associated with neurological deficits
Leg pain usually worse than back pain
Pain worse when sitting

Question 17

How does a spinal epidural abscess present?

Answer 17

Fever
Back Pain
Focal neurological deficits

Question 18

What is the pathophysiology of a spinal epidural abscess?

Answer 18

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

Question 19

What are the investigations for a spinal epidural abscess?

Answer 19

Blood culture
Inflammatory markers, HIV, Hep B, Hep C
Infection screen
MRI whole spine

Question 20

How does spinal metastases present?

Answer 20

Unrelenting lumbar back pain
Thoracic or cervical back pain
Worse with sneezing, coughing or straining
Nocturnal
Associated with tenderness

Question 21

What abdominal pathologies could present with back pain?

Answer 21

Pancreatic cancer 
Cholecystitis
AA
Perforating ulcer
Pyelonephritis

Question 22

Where does shoulder pain radiate to?

Answer 22

Upper arm

Question 23

Where does hip pain radiate to?

Answer 23

Anterior thigh

Knee

Question 24

What are the nerve roots of the sciatic nerve?

Answer 24

L4, L5, S1-3

Made up of the tibial nerve and common fibular nerve

Question 25

What is the definition of sciatica?

Answer 25

Irritation to the sciatic nerve of the spinal nerves that form it

Question 26

What are the spinal causes of sciatica?

Answer 26

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.

Question 27

What are the non spinal causes of sciatica?

Answer 27

Piriformis syndrome (causes inflammation, compression )
Pregnancy

Question 28

What are the symptoms and signs of sciatica?

Answer 28

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

Question 29

How do you diagnose sciatica?

Answer 29

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