Conditions of Back pain Flashcards
What is Low back pain?
Mechanical or non-specific low back pain
What is Sciatica?
Leg pain relating to compressive spinal pathology
What is Spondylosis ?
wear and tear of the spine, osteoarthritis
What is Spondylitis ?
an inflammatory disease of the spine
What is Spondylolysis ?
a defect or fracture of one or both wing shaped parts
of the vertebra. Can result in:
What is Spondylolisthesis ?
a slippage of the vertebra forward or backward over the one below
What is Spondylitis ?
an inflammatory disease of the spine
What is Acute back pain ?
Pain that lasts less than 6 weeks
when is it considered as Sub - acute back pain?
when the pain lasts between 6-12 weeks
What is chronic back pain?
More than 12 weeks
What are the causes of simple back pain?
Cause is unidentified
But in Gp, exclude something serious
What is the prognosis of back pain?
Most patients return to work within one month
What are the steps would you take if someone come in with Lower back pain?
Take a good history
Examine well
watch out for red flags
Don’t over-investigate - x rays are not usually indicated
How would you carry out history taking?
1) Circumstances -
2) Nature & Severity -
3) Other symptoms
4) PMH
5) Medication
6) Exclude any pain that from the back e.g renal pain
How would you ask to describe the pain ?
By using Socrates
Site
Onset
Character
Radiation
Association
Time
Exacerbation
Severity
What are the red flags for lower back pain ?
Age < 20 or > 55
Non-mechanical pain
Night time pain
- Spinal tumor
- osteomyelitis
- ankylosing spondylitis
Thoracic pain
Hx of ca
HIV/ Immune suppression
IV drug use
Steroid use
Unwell - FEVER
Weight Loss
Widespread neurological features
Spinal deformity
Numbness in the saddle area or bladder/bowel sphincter dysfunction
Cauda equina Lesion
medical emergency that happens when an injury or herniated disk compresses nerve roots at the bottom of your spinal cord
What is the Mnemonic for red flags ?
Sciatic Pain
S - Systemic illness ( Fever )
C - Constant pain /no relief
I - injury to the back
A - Age <20 /> 55
T - Thoracic pain & exam findings
I - Infection (TB, HIV) & inflammation (ankylosing spondylitis)
C - Cancer history
P - PAST HISTORY of back problems
A - (Mal)Alignment of the spine (Scoliosis)
I - Immunosuppressed (HIV, steroids, intravenous drug abuse)
N - Neurological signs – Bowel & bladder sphincter dysfunction; sexual dysfunction; lower limb motor impairment – especially if bilateral; sensory signs – especially if saddle anaesthesia
What are the main features you would look in the examination ?
defining the exact site of the pain
review of how the back can move
power in the limbs and toes
straight leg raising
Reflexes
What is the management of acute back pain?
If it is a fracture - Minor trauma/ osteoporosis ( Do an x-ray)
If it is cauda equina/ rapidly progressive neurological deficit - then do immediate referral
What if you find any red flags for back pain ?
Check FBC
ESR / (mets/myeloma/discitis/ AS)
Ca/ Alk phosphate (Paget’s disease tumor)
PSA, XR lumbar spine/pelvis
If the back pain has red flag and nerve root pain, what would you do?
Referral is not necessary
if resolves in less than 4 weeks
What is the investigation for simple backache?
Use Keel Star T
Do not x ray
What is Keel star T study consist of ?
Low risk
Medium risk
Higher risk
What would you recommend in pts with Low risk according to Keel start T study?
single session with a physio for self help advice, a back book or advice regarding analgesia
What would you reccemmend in pts with medium risk according to Keel start T study?
Standard physiotherapy
What would you recommend in pts with higher risk according to the Keel start T study?
Specialist physiotherapist who also explored patient’s distress and psychological issues
What is the scoring system of Keel Star T back pain scoring tool ?
Ask if they had the pain for the past 2 weeks ( score +1 for each )
- Does the pain spread down your leg?
- Have you had pain in the shoulder or neck?
- Only walked a short distance because of pain
- Are you dressing more slowly than usual
- it’s not safe for me to be physically active with a condition like mine
- worrying thoughts have been going through my mind a lot of the time.
- I’ve felt my back pain is terrible and not going to get better
- I’ve not enjoyed the things I used to enjoy
How are the Keele star T score classified ?
If the score is 3 or less, simple lumbago explain to the pt to move around and avoid to sit in the chair constantly and not to lie on the bed as it could make things worse.
Advice to keep good posture
Advice on paracetamol and Nsaids if they’re not contraindicated.
What is the contraindication with Nsaids?
Peptic ulcer
Asthma
What happens to the pt if they score 4 or more in Keele star T score?
If it is not resolved in 4 weeks time, refer to specialist soon before it gets worse or physical therapy
What analgesia would you give them?
- Paracetamol
- Ibuprofen - check for contraindication
- weak opioids ( do not give repeat prescription for opioids & do not use strong opiods )
- Consider to give them a short term muscle relaxant such as baclofen or diazapam
-
What analgesia would you use in people coming with Nerve root pain ?
Initially just paracetamol
If not cured, urgent referral for inpatient analgesia
if not resolved within 4-6 weeks referral to orthopaedics
if there’s any evident of cauda equina syndrome ( urgent telephone referral to orthopaedics or neurosurgery)
What is Spondylarthritis ?
- Group of disease with spinal and peripheral features
- common in both men & women
- affects 1 % of the population
- often run in families
- Do the test for HLA B27 and more often this will be present
What are the 2 main types of Spondylarthritis ?
Central predominant (Ankylsoing Spondylitis)
Peripheral features predominate ( Psoraitic arthritis - arthritis assoc with IBD)
Feature of ankylosing spondylitis
Inflammatory back pain
uveities
Psorasis
Inflammation of tendons where they join the bone
Dactylitis ( inflmmation of the fingers ) - common in both
What is the features of Psoriatic arthritis ?
Synovitis
uveities
Psorasis
Inflammation of tendons where they join the bone
Dactylitis ( inflmmation of the fingers ) - common in both
What is Ankylosing Spondylitis ?
5% of people with Lower back pain has this condition
pt can present with inflammatory back pain, pelvic pain and sciatica,
What finding would be seen on examining the pt. with ankylosing spondylitis ?
Decreased chest expansion
‘bamboo spine’ - on x-ray
Reduced spinal flexion on schober’s test
What is Psoriatic Arthritis ?
- 5% of people with Psoriasis will be affected
- can also get joint issues ( one or several)
- Check the nails for pitting
What is Reactive Arthritis ?
This presents following an infection
What are the organisms that could cause reactive arthritis ?
Campylobacter
Clostridium
Salmonella
Shigella
Yersinia Chlamydia
What is the presentation of reactive arthritis ?
Arthritis
Urethritis
Conjuctivities
What is Enteropathic arthritis ?
It affects 1/5th of the patient with inflammatory bowel disease
What does the patient with HLA B27 are more prone to?
Inflammation in the sacro illiac region called sacroiliitis
What is the management for the Arthritis ?
-NSAIDS
-Physiotherapy
-Refer to rheumatology for further management
-DMARDS
- biological drugs
- urgent ophthalmology if eye symptoms occur such as redness, pain, photophobia and blurring
What is the term sciatica ?
Sciatica is where the sciatic nerve, which runs from your lower back to your feet, is irritated or compressed
What fraction of adults suffer from lower back pain each year ?
1/3 rd
What is the peak age prevalence of Lower back pain ?
45 - 60
95 % of LBP resolves within how many weeks ?
6 weeks
Which is the screening tool used in the management of back pain ?
Start Score
What test do you use to measure the amount of spinal flexion ?
Schober’s test
Which nerve root is involved in patient present with unilateral sensory change in the outer shin and dorsum of the foot ?
L5
Which symptom is considered to be a red flag in back pain?
Night time pain
What is the peak age prevalence of LBP?
45-60
You are a PA in General Practice and see Mrs Smith an 84 year old lady. She is usually well but recently stumbled though didn’t seem to sustain any injury. For the 4 days since the fall she has had a
pain in the midback. On examination she is very tender over the first lumbar vertebra but examination is otherwise normal. List your differential diagnosis starting with the most likely first.
Fracture
Mr Pauling is 40. He works in a warehouse often lifting boxes. He presents at your surgery with lower backache for a week. He denies any acute trauma and is otherwise well. Examination reveals
some lumbar muscular spasm and pain limited range of spinal movement. What is your likely diagnosis and how would you manage him?
Simple Lumbago
Mr Osler is 68 and has been treated for prostatic cancer in the past. He presents with lower back pain for 6 weeks. He describes it as getting worse and keeps him awake at night. What are you
suspicious of and how would you manage him?
Metastatic Bone disease
Mr Atkins is 58 and complains of back pain when he follows his wife around the supermarket. He mentions its eased by lifting his foot onto the lower frame of the shopping trolley or finding a seat
somewhere. What might be a probable cause for his pain?
Spinal Stenosis
Mr Smith is 62 and attends urgently. He gives a history of pain in the buttocks, thighs and down his legs. He recently had some faecal incontinence which has led to his urgent appointment. The pains
pass off after about half an hour. On examination you find perianal numbness, a lax anal sphincter and some lower motor neurone weakness in the legs and loss of ankle reflex. What is the most
important possible diagnosis and is it urgent?
Cauda Quiana
