Clinical Lecture 2: Back Pain

Question 1

How can the spine change with age?

Answer 1

The spine with age:

- Disc lose water and lose strength and become thinner 
- Vertebral endplates and underlying bone structure loses strength
- Repetitive loading/trauma can result in annular tears in the disc
- Dryer, weaker discs result in slacker ligaments 
- Spine is less flexible
- New bone grows (osteophytes) to try and stabilise the spine 
- Increased load over the facet joints - this is seen in difficulty in lumbar spine extension

Question 2

What are the risk factors for mechanical back pain?

Answer 2

• Genetics
  
  • Environment
  • Body weight - obesity
  • Muscle strength in different areas e.g. forgetting to work out the lower back,
  • Mechanical loading strengths vertebral bodies and increase the water content within discs e.g. builders - Overloading should be avoided
  • Occupation e.g. heavy physical jobs, lifting, driving to work, previous episodes of lower back pain, posture and mental health.

Question 3

What is simple back pain?

Answer 3

This is the pain most people with back pain experience. Patient often experience their first episode while lifting/twisting/turning. Simple back pain shows variable pain related to position and posture and is particularly better when laying down. The pain may radiate down to the buttock or leg.

Question 4

In what percentage of patients with simple back pain do we see degenerative changes on the X-Ray?

Answer 4

On X-Ray we are looking for facet joint changes, osteophytes and disc narrowing - these are classical in degenerative changes in the spine. We see this in around 100% of patients, as a result we do not need to X-Ray all patients with back pain.

Question 5

How is simple back pain managed?

Answer 5

Management:

- Simple analgesics 
- Physiotherapy if necessary 
- Rest for no longer tan 1-3 days - they need to keep moving 
- Psychosocial management 
- Work absence only if avoidable 
- Consider secondary care referral if over 6 weeks 

Medication:
- Paracetamol
- NSAIDs? (shortest dose for the shortest time as it can cause gastric pain in the end)
- Opioids (try and avoid - though co-codamol can be used in the sort term)
- Anti-depressants (amitriptyline, duloxetine)
Nerve modulators (gabapentin, pregabalin) - these are controlled drugs. They can be difficult to wean down

Question 6

What is Sciatica?

Answer 6

The Sciatic nerve originates from L4-S3. Sciatica is an intense pain from below the knee. It has a very sudden onset. It is the most common cause of nerve root pain. It may be associated with pins and needles in the legs. The most common cause is a slipped disc.

They will not be able to stand on one knee - so they void weight bearing on the affected leg. It may be associated with numbness and weakness.

Treatment includes physiotherapy and medication.

The commonest neurological sign is loss of ankle jerk and is foot drop.

Question 7

Give possible serious causes of spinal pathology.

Answer 7

• Degenerative disease
  
  • Axial spondylarthritis
  • Osteoporosis
  • Osteomalacia
  • Paget’s disease
  • Infection
  • Tumour

Question 8

What are red flag symptoms of back pain?

Answer 8

• Age (young or old) at first onset
  
  • History of carcinoma - Breast, Lung, Prostate, Kidney and thyroid
  • Weight loss
  • Constant (24h) pain > 1 month - if pain at rest this can be inflammatory
  • No response to treatment
  • Pain worse at rest
  • History of IV drug use (due to risk of discitis) or HIV positivity or immunosuppression (poorly controlled)
  • Infections

Question 9

What the signs of inflammatory back pain in a history?

Answer 9

• Insidious onset
• nocturnal pain with marked early morning stiffness
• Better with exercise
• Family History
• Buttock pain
• Often occurs in younger people and men

Question 10

What are risk factors for osteoporosis?

Answer 10

Osteoporosis is very common. It leads to the vertebral bodies collapse. It is not through trauma. It is treatable. It does not give you pain until you fracture - it is the ‘silent disease.’

Risk factors:

- Age 
- Women (oestrogen drop after menopause and so the drop in bone density)
- Smoking 
- Steroids use
- Alcohol 
- Family history 
- Inflammatory conditions

Question 11

What is Paget’s disease?

Answer 11

Paget’s disease of bone is a chronic disease of the skeleton. In healthy bone, a process called remodeling removes old pieces of bone and replaces them with new, fresh bone. Paget’s disease causes this process to shift out of balance, resulting in new bone that is abnormally shaped, weak, and brittle.

- The X-Ray shows the bone on the left becomes denser and most sclerotic. It may be denser and thicker but it is more prone to fracture
- The most common site is the pelvis but it can occur in the femur 
- Can also cause deafness (or cranial nerve palsy) if in the skull  Most common finding is incidental 

- Often asymptomatic - raised alkaline phosphatase 
- Increases prevalence with age