Lombalgies Flashcards
Mechanical back pain
ge 20–55 yrs
>90% present with low back pain
Pain arises from ligaments, discs, facet joints
Unnecessary to differentiate exact cause
High recurrence Associated with depression
Pain in lower back, lateral thigh or buttock
Back pain > limb pain
Pain varies between and during episodes
Pain worse with certain postures
Normal neurological examination
Normal straight leg raise
No bony tenderness
Exclude depression and red flags
Red flags:
Age <20 yrs or >55 yrs Abnormal neurology Thoracic pain
Weight loss
Fever
History of malignancy Use of systemic steroids
Prolapsed lumbar disc
Prolapse of nucleus pulposus Impinges on lumbar nerve roots Age 20–50 yrs
Associated with sciatica
Low back pain
Radiates to foot or toes Unilateral leg pain > low back pain
Paraesthesia in distribution of pain
Straight leg raise induces pain Focal neurology limited to one nerve root
Vertebral fracture
History of major back trauma Or minor trauma in
pathological bones
Consider pathological fracture if:
History of malignancy, osteoporosis, steroid use, weight loss, thoracic pain, systemic upset
Acute onset back pain
Constant pain
Worse on lying supine
New onset deformity of spine
Loss of height
Bony tenderness
Palpable vertebral step
New kyphosis or scoliosis
Refer for X-ray
Vertebral body/disc infection
Infection of a vertebral body or intervertebral disc
Commonly i.v. drug users and immunosuppressed
Causes include: TB and staphylococci
Severe pain in lower back
Worse with rest Relieved by movement
Malaise
Fever
Tender over intervertebral disc or vertebral body
Palpable warmth
± Erythema of overlying skin
± Kyphosis in vertebral collapse ± Groin abscess
± Lower-limb neurology
Emergency admission
Malignancy
Previous history of malignancy
Common primary tumours: Breast, lung, prostate
Primary bone cancer is rare
Back, rib or hip pain Worse at night Weight loss Malaise Symptoms of hypercalcaemia: Lethargy Low mood Polyuria Polydipsia Constipation Muscle weakness
Bony tenderness
Occasional soft tissue masses
Gradual progressive neuropathy Hepatomegaly
Pathological fractures
Multiple myeloma
Malignant plasma cell proliferation
Bone marrow infiltration Bone destruction and marrow
failure
Commonly age >50 yrs
M>F
Associated with: Urinary Bence
Jones proteins and serum monoclonal protein (e.g. IgG)
Bone pain (typically back, femur, pelvis)
Lethargy
Anorexia
Bruising
Symptoms of hypercalcaemia:
Lethargy
Low mood Polyuria Polydipsia Constipation Muscle weakness
Anaemia
Bony tenderness Pathological fractures
± Spinal cord/nerve root
compression
Complications include:
Hyperviscosity, amyloidosis, renal failure
Urgent referral to haematology
Paget’s disease of the bone
Abnormal osteoclast activity Disorganised bone remodelling Results in larger and weaker bones
Age >40 yrs
M>F
Commonly affects spine, skull and long bones
≈1% cases develop sarcoma
Often asymptomatic or
Dull bony pain (e.g. backache) Worse on weight bearing Progressive bone deformity Deafness
Bowing of tibia, femur and/or forearm
Frontal bossing
Deafness (CN VIII compression) Pathological fractures (e.g. femur)
Ankylosing spondylitis
Seronegative spondyloarthopathy Facet joint and sacro-iliac joint inflammation
Results in spinal fusion Age 18–40 yrs
M>F
Caucasian predominance ≈90% HLA-B27 positive Positive family history
Low back pain
Progressively worse over months Gradually involves thoracic spine Early morning back stiffness Relieved by activity
Reduced spinal movements
Lumbar lordosis persists on forward flexion
Pain over iliac crests
Reduced chest expansion <5 cm
Extra-articular signs:
Inflamed swelling at insertion of
Achille’s tendon Anterior uveitis Aortic regurgitation Pulmonary fibrosis
Lumbar cord compression
Common causes: Trauma, malignancy, prolapsed intervertebral disc above L1 level
Acute or gradual onset symptoms Paraesthesia in legs or perineum
Difficulty passing or stopping urine
Faecal incontinence
Tender lumbar vertebrae Lower limb weakness Lower limb sensory deficit Saddle anaesthesia UMN signs in lower limbs: Spasticity Hyperreflexia below level of lesion Upgoing plantars ± Loss of anal tone and sensation
Refer for emergency admission
Delayed treatment can cause permanent neurological deficit
Lumbar spondylolisthesis
Displacement of vertebral body on the one below
Displacement is typically forwards Commonly involves L4/5 or L5/S1 Causes: Spondylosis due to
stress fracture, dysplasia of lumbosacral joints, OA degeneration
Commonly athletes and gymnasts
Children usually asymptomatic Adolescent or adult symptoms: Chronic backache Radiates to buttocks Worse after standing and exertion ± Sciatica
Signs in children: Enhanced lordosis Waddled gait Adolescent or adult signs: Flattened buttocks due to disuse Significant transverse loin creases Visible or palpable vertebral step ± Limited straight leg raise (if sciatica) ± Reduced ROM of spine
Spinal stenosis
Narrowing of the spinal canal Due to hypertrophy at the posterior disc margin and facet joints
Commonly >60 yrs age Causes:
Chronic disc
degeneration and OA
Aching of lower limbs Numbness and paraesthesia in lower limbs
Symptoms worse on standing or walking for 10 mins Relieved by sitting or squatting against a wall to flex spine
At rest: Normal straight leg raise Normal lower limb pulses No focal neurology Post-exertion: Often unilateral signs Focal neurological signs in lower limbs
Unlike claudication, pain is not relieved by standing still
Cauda equina syndrome
Common causes: Lumbar disc prolapse, spinal tumour or trauma, spinal abscess
Acute or gradual onset symptoms Low back pain Pain radiates to one or both legs Difficulty passing or stopping urine Faecal incontinence
Lower limb weakness
Lower limb sensory deficit Absent lower limb reflexes
Saddle anaesthesia
± Loss of anal tone
Refer for emergency admission
Delayed treatment can cause permanent neurological deficit
