Back Pain & Spinal Disorders

Question 1

What are the generalised causes of back pain? [5]

Answer 1

1. Mechanical wear & tear (97%)
   
   • = non-specific low back pain (NSLBP)
2. Systemic
   
   • Infection
   • Malignancy
   • Inflammatory
3. Referred (i.e. no pathology in back)

Question 2

What are the clinical features of “mechanical” back pain/non-specific low back pain (NSLBP)? [4]

Answer 2

1. Onset at any age, variable rate
2. Generally worsens with movement or prolonged standing
3. Better with rest
4. Early morning stiffness <30mins

Question 3

What are the causes of mechanical back pain? [6]

Answer 3

1. Lumbar strain/sprain
   
   • most common cause
   • muscle spasms usually settle 24-48hrs
2. Degenerative disc disease (“spondolysis”)
   
   • many = asymptomatic disc disease
   • increase with flexion, sitting, sneezing
3. Degenerative facets joint disease
   
   • more localised
   • increase with extension
4. Disc prolapse
5. Spinal stenosis
6. Compression fractures

Question 4

How do you manage mechanical back pain? [5]

Answer 4

1. Keep diagnosis under review
2. Reassurance
3. Education, promote self-management
   
   • advise to stay active
   • exercise programme and physiotherapy
4. Analgesics as appropriate (avoid opiates)
5. Also acupuncture

Question 5

What is a disc prolapse? [1]

Answer 5

herniated nucleus pulposus

Question 6

Where is the pain generally found in a disc prolapse? [2]

Answer 6

leg → back pain

Question 7

What examination tests are done on a patient with suspected disc prolapse and what would these show? [2]

Answer 7

1. test reflexes: ↓reduced reflexes
2. straight leg test: would test +ve

Question 8

What is a positive straight leg test?

Answer 8

pain between 30-70°

Question 9

In which direction does the nucleus pulposus tend to prolapse (anteriorly/posteriorly/superiorly/inferiorly)? [1]

Answer 9

posteriorly

Question 10

What are the symptoms of cauda equina? [4]

Answer 10

1. Neuropathic symptoms
   
   • bilateral sciatica
   • saddle anaesthesia
2. Bladder or bowel dysfunction
   
   • reduced anal tone

Question 11

What is cauda equina usually caused by? [1]

Answer 11

a large prolapsed disc

Question 12

What is spinal stenosis? [2]

Answer 12

Anatomical narrowing of spinal canal that can be congenital and/or degenerative

Question 13

What does spinal stenosis often present with? [1]

Answer 13

Often presents with “claudication” in legs/calves

Question 14

What is spondylolisthesis and where does it usually occur?

Answer 14

1. “slip” of one vertebra on the one below - anterior displacement of a vertebral disc
2. often at L5 level

Question 15

Describe the pain that is commonly present in spondylolisthesis [2]

Answer 15

1. Pain may radiate to posterior thigh
2. Increase with extension

Question 16

What are the presenting features of compression fracture? [3]

Answer 16

1. Often sudden severe onset of pain
2. Radiates in “belt” around chest/abdomen
3. Associated osteoporosis

Question 17

What investigations would you do on a patient with a suspected compression fracture? [2]

Answer 17

1. X-ray
2. DEXA scan

Question 18

What are the causes of referred back pain? [6]

Answer 18

1. Aortic aneurysm
2. Acute pancreatitis
3. Peptic ulcer disease (duodenal)
4. Acute pyelonephritis/Renal colic
5. Endometriosis/gynae

Question 19

What are the distinctive presenting features of an aortic aneurysm? [3]

Answer 19

1. CVS features (BP, THR)
2. collapse,
3. pulsating abdominal mass

Question 20

What are the distinctive presenting features of acute pancreatitis? [3]

Answer 20

1. epigastric pain,
2. relief if lean forwards,
3. unwell

Question 21

What are the distinctive presenting features of peptic (duodenal) ulcer disease? [4]

Answer 21

1. epigastric pain (after meals),
2. history of peptic ulcer disease,
3. vomit,
4. blood/melaena

Question 22

What are the distinctive presenting features of acute pyelonephritis/renal colic? [6]

Answer 22

1. history of UTI
2. history of stones,
3. unwell,
4. radiation,
5. haematuria,
6. frequency

Question 23

What are the systemic causes of back pain? [3]

Answer 23

1. Infection — discitis, osteomyelitis, epidural abscess
2. Malignancy
3. Inflammatory

Question 24

Describe infective discitis under the following headings:

1. signs & symptoms? [4]
2. who gets it? [3]
3. investigations? [3]
4. microbiological causes? [1]
5. treatment options? [2]

Answer 24

1. Signs & Symptoms:
   
   • High index of suspicion
   • Fever (may be PUO),
   • Weight loss
   • Constant back pain — rest, night pain
2. Who gets it?
   
   • Immunosuppressed,
   • Diabetics,
   • IV drug users
3. Investigations:
   
   • Bloods: FBC, ESR, CRP, blood cultures
   • Imaging x-ray (end-plate/vertebral destruction), MRI
   • Radiology-guided aspiration
     
     • Look for the source
4. Microbiological causes:
   
   • Most commonly Staph aureus
5. Treatment:
   
   • IV antibiotics
   • ± surgical debridement

Question 25

Describe the features of malignancy as a systemic cause of back pain under the following headings: 1. risk factors/which maligancies put u at increased risk? [5] 2. typical age of onset? [1] 3. signs & symptoms? [4] 4. investigations? [3]

Answer 25

1. Risk factors: * History of malignancy: "LP Thomas Knows Best" * lung, * prostate, * thyroid, * kidney, * breast 2. Onset age \>50yrs 3. Signs & Symptoms: * Constant pain, often worse at night * Systemic symptoms * Primary tumour signs & symptoms 4. Investigations: * X-ray (lytic/destructive), * MRI, * bone scan * look for primary source

Question 26

Describe the features of inflammatory back pain under the following headings: 1. age of onset? [1] 2. signs & symptoms? [5]

Answer 26

1. Onset \<45 years (often teens) 2. Signs & symptoms: * Early morning stiffness \>30mins * Back stiff after rest & improves with movement * May wake 2nd half night * Buttock pain

Question 27

What are the red flags associated with back pain? * symptoms? [10] * signs? [5]

Answer 27

* Symptoms: 1. New onset age \<16 or \>50 2. Following significant trauma 3. Previous malignancy 4. Systemic = fevers/rigors, general malaise, weight loss 5. Previous steroid use 6. IV drug abuse, HIV or immunosuppressed 7. Recent significant infection 8. Urinary retention 9. Non-mechanical pain (worse at rest "night pain") 10. Thoracic spine pain * Signs: 1. Saddle anaesthesia 2. Reduced anal tone 3. Hip or knee weakness 4. Generalised neurological deficit 5. Progressive spinal deformity

Question 28

What are the yellow flags associated with back pain? [7]

Answer 28

1. **Attitudes** * towards the current problem. 2. **Beliefs** * misguided belief that they have something serious 3. **Compensation** * awaiting payment for an accident/ RTA? 4. **Diagnosis** * **inappropriate communication**, patients misunderstanding what is meant, * examples being 'your disc has popped out' or 'your spine is crumbling'. 5. **Emotions** * other emotional difficulties e.g. depression/ anxiety 6. **Family** * either over bearing or under supportive. 7. **+ Work relationship**

Question 29

Describe the differences between **mechanical** vs. **inflammatory** back pain under the following headings: 1. age of onset? [2] 2. features of onset? [3] 3. duration of morning stiffness? [2] 4. effect of exercise? [2] 5. effect of rest? [2] 6. symptoms at night-time? [2]

Answer 29

1. _age of onset_ * mechanical = any age * inflammatory = usually \<40yrs 2. _features of onset_ * mechanical = variable, may be acute * inflammatory = insidious 3. _duration of morning stiffness_ * mechanical = \<30mins * inflammatory = \>30mins 4. _effect of exercise_ * mechanical = may worsen pain * inflammatory = improves pain & stiffness 5. _effect of rest_ * mechanical = often improves * inflammatory = no improvement 6. _symptoms at night-time_ * mechanical = may improve * inflammatory = may wake during second half of night