Backache Flashcards
What features of the history are most important in backache?
Onset of pain Previous episodes Site and nature of pain Radiation of pain Neurological symptoms
SOCRATES
What social features of the history are important in diagnosing backache?
age
Occupation
Litigation (legal issues)
Why is it important to be aware of the patient who knows the exact time and date their back pain started?
Back pain = usually insidious in onset
=> someone who attributes all their back problems to a given event may have secondary issues
What features would be considered suspicious or “red flags” in a back pain history?
Non-mechanical pain
Systemic upset
Major OR new neurological deficit
Saddle anaesthesia +/- bladder or bowel upset
What types of physical tests can you carry out on examination?
Observation Range of movement Neurological assessment Nerve root irritation Distraction testing
What should you look for when observing the spine from the posterior and lateral sides?
deformity asymmetry hairy patches neurofibromata potential muscle spasm Normal lordosis and Kyphosis
During Schober’s test, what are the lower and upper limits of normal?
<18cm = pathologically stiff >24cm = hypermobile
What type of deformity is easily noticed on asking the patient to lean forward and touch their toes?
Scoliosis
spine appears rotated
What nerve roots are responsible for hip flexion?
L1/L2
What movements are nerve roots L3/4 responsible for?
Knee extension
What movement does the nerve root from L5 control?
Ankle dorsiflexion
What nerve roots are in control of plantar flexion of the foot?
S1/2
What examination tests nerve irritation?
Straight leg raise test
What movements do you test when doing a femoral stretch?
hip extension and knee flexion
to put as much pressure on femoral nerve as possible
What characteristics are considered “overt” pain behaviour?
Guarding Bracing Rubbing Grimacing Sighing
What behavioural responses to examination can indicate an over-exaggeration of backache?
Superficial / non anatomical tenderness
Over-reaction to examination
Distraction test (minimal straight leg raise, but can sit bolt upright|)
Why should you be aware of X-Ray changes in back pain?
They may just be age related degeneration and not the source of the back pain
What specialised investigations may be used in back pain?
MRI - but beware not diagnostic!! Diagnostic facet injection Contrast enhanced CT Provocation discography Selective nerve block / ablation
How do surgeons usually define sciatica?
Buttock and / or leg pain in a specific dermatomal distribution accompanied by neurological disturbance
Surgery on patients with disc prolapse is mainly to relieve the back pain. TRUE/FALSE?
FALSE
relieves the leg pain by removing fragment of disc that is on nerve roots
How does disc prolapse usually present?
Episodic back pain
Onset of leg pain +/- neurology
Leg pain becomes dominant
Myotomes and dermatomes
Disc prolapse is not a medical emergency. TRUE/FALSE?
TRUE
look out for cauda equina syndrome as this IS a medical emergency
How long does it take for a disc prolapse to settle itself?
70% will settle in 3 months
90% will settle in 18 – 24 months
How is disc prolapse treated?
Conservative treatment first
Consider surgery if not resolving after 3 months
**long term results = not much different with surgery
What is meant by “conservative treatment” for backache?
Short bed rest (debatable) Anti-inflammatory +/- muscle relaxant Mobilise thereafter Place of physical therapies, X-ray etc Return to normal activity
What is meant by secondary backache treatment?
Physiotherapy Osteopathy / chiropractic TENS / psychology / Pain Clinic Complementary therapies Surgery
How many people are left with failed back surgeries?
Up to 25% failure rate
3 – 5% worse off than previously
