Back pain & Sciatica

Question 1

What are important things to ask about in a presenting complaint of back pain?

Answer 1

• onset
• character (dull, stabbing, throbbing)
• location and radiation (buttocks, below knee)
• duration (acute vs. subacute vs. chronic >1 year)
• intensity
• associated symptoms (stiffness, numbness, urinary symptoms)
• aggravating factors (position, valsalva, stairs)
• relieving factors (position, analgesia, alternative)

Question 2

State the points to include in systemic review

Answer 2

Fever, weight loss, abdominal pain, cough, haematuria, dysuria, menstruation

Question 3

What drugs are important to note in a history?

Answer 3

Corticosteroids, immunosuppressants, anti-platelet/coagulation

Question 4

What should you ask about family history?

Answer 4

Cancers
Back pain
Spondyloarthropathies

Question 5

What should be included in social history

Answer 5

Occupation
Smoking
Recreational drug use
Sporting activities

Question 6

State the general red flags for back pain

Answer 6

Failure to improve after 4-6 weeks of conservative therapy, night pain/pain at rest, motor/sensory deficit

Question 7

Name the cancer red flags for back pain

Answer 7

Age >50, weight loss, history of cancer, pain at night/rest

Question 8

State the infection red flags

Answer 8

Fever/chills, recent infection, immunosuppression, IV drug use, dental status, foreign travel

Question 9

What are the fracture red flags?

Answer 9

> 50 years old, osteoporosis, trauma, chronic steroid use

Question 10

Name the red flags for cauda equina

Answer 10

Bilateral sciatica, urinary incontinence, decreased anal tone, saddle anaesthesia, leg weakness

Question 11

What are the red flags for AAA?

Answer 11

Age >60, abdominal pulsating mass, pain at rest

Question 12

State the additional tests in a spinal examination

Answer 12

Straight leg raise
Muscle strength
Sensation
Deep tendon reflexes

Question 13

What is Hoffmans Test?

Answer 13

Flick nail of middle finger, positive if flexion of the thumb/index finger occurs

Question 14

What is the babinski test?

Answer 14

Run a sharp instrument down the centre of the foot and normally toes should flex but in pathology toes will extend

Question 15

What percentage of back pain will resolve within a month?

Answer 15

70-90%

Question 16

When is an X-ray used?

Answer 16

Young men - ank spond at SI joint
Elderly to exclude fracture or malignancy
To view a deformity

Question 17

When is a CT scan indicated?

Answer 17

Bony pathology (tumour, trauma, infection)
Foreign body/ implants
Spinal fusion planning
If MRI is contraindicated or unavailable

Question 18

When is a MRI used?

Answer 18

Provides soft tissue details, used for red flags and neurological signs/symptoms

Question 19

What can be seen on a radionuclide scan?

Answer 19

Mets/tumour - osteoid osteoma

Increased bone turnover in diseases like pagets

Question 20

What is sciatica?

Answer 20

Sciatic nerve or nerve root compression

Question 21

How does sciatica present?

Answer 21

Pain/numbness/weakness worse on flexion of the lumbar spine, twisting or coughing. Radiates down the leg potentially the side of the foot. Weakness of muscles which help to stand on tiptoes and ankle reflex may be diminished or absent.

Question 22

What differentials should be considered in sciatica?

Answer 22

Degenerative disease
Tumour, fracture, TB
Compression outwith the spine - piriformis syndrome, endometriosis
No root compression - arachnoiditis, neuropathies

Question 23

What is piriformis syndrome?

Answer 23

Compression of sciatic nerve by piriformis mucles - sitting on wallet

Question 24

How is sciatica treated?

Answer 24

Usually conservative unless red flags