Clinical approach to back pain: diagnosis and management in the NHS Flashcards
In cervical spine, what nerve is affected with disc herniation?
Mismath e.g. disc herniation of C5 will affect C6 nerve root, C2 will affect C3 nerve root etc
In lumbar spine, lateral bulging affects which nerve?
corresponding nerve e.g. L4 bulging affects L4 nerve root
In lumbar spine: if paracentral disc herniation occurs, which nerve root is affected
the nerve that traverses it e.g. one below- L4 bulge will affect L5 nerve
2 ways to classify back pain
structural
duration
define mechanical back pain
“pain secondary to overuse of a normal anatomic structure or pain secondary to trauma or deformity of an anatomic structure”
clinical features of mechanical back pain
Younger patients – 20 to 55 years Patient well Characteristic distribution Good prognosis 90 % recovery within 6 weeks
nerve roots of sciatic nerve
L4-S3
what is neurogenic claudication
pain is worse on extension of spine- e.g. walking or standing upright, and relieved by forward flexion- when they lean forward or sleep in foetal position
clinical features of nerve root tension or sciatica
Unilateral leg pain > back pain Radiation to below knee to foot/toes Numbness and paraesthesia Signs of nerve root irritability (single) Motor, sensory or reflex changes Reasonable prognosis Majority improve after 6 to 12 weeks
clinical features of inflammatory back pain
Aged 20 to 40 years (5:1 M to F) Slow onset of symptoms Chronic (eg > 3 to 6 months) Morning stiffness and better with activity Usually axial skeleton Extraskeletal features Uveitis, CVS, Lung etc
3 non-spinal causes of back pain
ulcers
kidney problems
aortic aneurysms
onset of acute back pain?
less than 6 months
onset of chronic back pain?
greater than 6 months
general management of back pain
Education Multidisciplinary approach -Physical treatment -Psychological support Teaching coping mechanisms Reassure regarding activity, work and lack of serious illness Medication encourage mobility
management of nerve root tension
Further sub-diagnosis can be helpful: Education, analgesia, physical activity
Encourage mobility
Reasonable prognosis
Majority improve after 6 to 12 weeks
May need imaging and surgery if no improvement with conservative therapy
management of inflammatory back pain
Education Physical treatment NSAIDs Disease modifying drugs -Sulphasalazine -Methotrexate Treatment of extra-articular features
commonly used drugs in management of back pain
Simple analgesia eg paracetamol
NSAIDs / Cox-2 inhibitors
Non-opiate analgesics
Tricyclic antidepressants- NOT RECOMMENDED BY NICE
Steroid injections
Opiates
non-pharmacological therapies for back pain
TENS Acupuncture Reflexology Relaxation therapies Pain management eg distraction
components of back pain history
Age of patient
Onset and duration of symptoms
Location of pain
Radiation: Thighs (usually referred), below knees (usually neurogenic)
Systemic features: anorexia, weight loss, nocturnal pain
Other musculoskeletal symptoms
Things that help pain: Posture, exercise, medication
Past medical history
Family History
Occupational history
Functional history
A to F of function assessment
A- ambulation B-bathing C-continence D- dressing E- emotional state F- feeding
results of the sciatic stretch test
Often positive: If they have sciatica the pain should be below the knee, pain should happen between 30-60/70 degrees.
If pain happens between 0-30= Negative SLR
Less than 30 degrees could indicate hip pathology e.g. osteoarthritis
If pain is in the back, could mean stiff back
Above 70 degrees pain in the thigh- tight hamstrings
Positive femoral stretch test
pain in anterior thigh
non MSK exams to consider
Urinalysis
Rectal examination
Herniae
Pulses
