Low Back Pain

Question 1

What is the definition of lower back pain?

Answer 1

• pain between bottom of the ribs and the top of the legs

Question 2

Lower back pain is defined as pain between the bottom of the ribs and the top of the legs. What is the definition of acute (A), sub-acute (SA) and chronic (C) lower back pain?

1 - A = <6 weeks, SA = 6-24 weeks, C = >24 weeks
2 - A = <4 weeks, SA = 4-16 weeks, C = >16 weeks
3 - A = <6 weeks, SA = 6-12 weeks, C = >12 weeks
4 - A = <2 weeks, SA = 2-12 weeks, C = >12 weeks

Answer 2

3 - A = <6 weeks, SA = 6-12 weeks, C = >12 weeks

Question 3

What is the definition of mechanical back pain?

Answer 3

• joints, discs, muscles and connective tissue make up mechanics
• mechanical pain is when the mechanics are impaired causing pain

Question 4

In addition to mechanical pain, the GP must rule out what 2 other causes of back pain?

Answer 4

• nerve root pain

- spinal pathology (malignancy, infection, fracture, inflammation)

Question 5

Ankylosing spondyilitis can be broken down into the following:

• ankylosing = stiffness
• spondy = spine
• itis = inflammation

What is ankylosing spondyilitis?

Answer 5

• autoimmune disorder causing inflammation of the spinal joints

Question 6

Ankylosing spondyilitis can be broken down into the following:

• ankylosing = stiffness
• spondy = spine
• itis = inflammation

Ankylosing spondyilitis is an autoimmune disorder causing inflammation of the spinal joints. What 2 joints of the spine are commonly affected?

Answer 6

• facet joints

- intervertebral discs

Question 7

Ankylosing spondyilitis can be broken down into the following:

• ankylosing = stiffness
• spondy = spine
• itis = inflammation

Ankylosing spondyilitis is an autoimmune disorder causing inflammation of the spinal joints, specifically the facet joints and the intervertebral discs. In humans we have genes on chromosome 6 that encode the human leukocyte antigen (HLA) which identify self cells that MHC-1 molecules can bind with to identify cells are our own. However, patients with ankylosing spondylitis commonly have the same HLA gene that has been linked with ankylosing spondyilitis. What gene is this?

1 - HLA-A1
2 - HLA-A27
3 - HLA-B1
4 - HLA-B27

Answer 7

4 - HLA-B27

- cytotoxic CD8 cells bind to the MHC-1 encoded by HLA-B27 and cause immune response

Question 8

In a patient with lower back pain, what are 5 key red flag symptoms?

Answer 8

• night pain keeping patient awake
• loss of bowel and urinary control (could be cauda aquina)
• numbness around back passage (could be cauda aquina)
• fever and weight loss
• thoracic pain

Question 9

In a patient with lower back pain, 2 red flag symptoms are loss of bowel and urinary control and numbness around the back passage. What are 2 important diagnosis that must not be missed in a patient with the red flag symptoms that are dangerous?

Answer 9

• cauda equina syndrome

- cancer

Question 10

Saddle anaesthesia refers to reduced sensation in the area that would be in contact with a saddle if sitting on one. What is a common cause of this?

1 - fragility fracture
2 - nerve root pain
3 - malignancy
4 - fractured coccyx

Answer 10

2 - nerve root pain

Question 11

If a patient presents with lower back pain, is imaging generally useful?

Answer 11

• no

- generally does not identify cause

Question 12

What does the mnemonic SOCRATES stand for?

Answer 12

• S = site of pain
• O = onset of pain
• C = character of pain (sharp or dull)
• R = radiates
• A = associated features of the pain
• T = timing of pain
• E = exacerbating and relieving factors
• S = severity of pain

Question 13

If a patient has previously had cancer and is in remission, but is now experiencing back pain, what could be the cause of the back pain?

Answer 13

• metastatic and cancer of the vertebrae

Question 14

If we perform blood tests in a patient with lower back pain, what are we likely to measure?

Answer 14

• inflammatory markers

Question 15

What blood markers would suggest malignancy if they were raised in a patient with back pain?

1 - Ca2+, alkaline phosphatase, creatine kinase
2 - alkaline phosphatase, creatine kinase, prostate specific antigen
3 - alkaline phosphatase, Ca2+, prostate specific antigen
4 - Ca2+, prostate specific antigen and creatine kinase

Answer 15

3 - alkaline phosphatase (ALP), Ca2+, prostate specific antigen (PSA)

• ALP and Ca2+ would suggest tumour degrading bone
• PSA would suggest primary malignancy site

Question 16

What cause of lower back pain if suspected should be referred to admission to a neurological assessment as soon as possible?

1 - torn muscle
2 - cauda aquina syndrome
3 - fragility fracture
4 - herniated disc

Answer 16

2 - cauda aquina syndrome

Question 17

If a patient has suspected malignancy associated with lower back pain, what should the GP do?

Answer 17

• refer the patient on a 2 week pathway to see oncologist

Question 18

What does radiculopathy mean?

Answer 18

• refers to mechanical compression of a nerve root

- results in nerve root associated pain

Question 19

What is the most common cause of radiculopathy?

Answer 19

• disc herniation

Question 20

What are the most common symptoms of radiculopathy?

Answer 20

1 - numbness
2 - weakness
3 - loss of tendon reflexes

Question 21

Patients with radiculopathy can present with numbness, weakness and loss of tendon reflexes. What simple method can be used to confirm this in a patient?

1 - stretch the sciatic nerve
2 - EEG
3 - ECG
4 - sensation testing

Answer 21

1 - stretch the sciatic nerve

Question 22

In a patient with radiculopathy they can present with numbness, weakness and loss of tendon reflexes, which can be accentuated by stretching the sciatic nerve. If a patient had significant muscle wasting and weakness, a positive babinski test that is progressive, what must be done with the patient?

1 - placed on standard waiting list for a neurologist
2 - placed on standard waiting list for a orthopaedic surgeon
3 - placed on the urgent list for a neurologist
4 - placed on the urgent list for an orthopaedic surgeon

Answer 22

3 - placed on the urgent list for a neurologist

- symptoms suggest significant or permanent nerve damage

Question 23

Disc herniate at what level is the most common cause of cauda aquina. What disc is most commonly affected?

1 - L4-5 or L5-S1
2 - T12-L5
3 - L4-S1 or L3-S1
4 - L5-S1

Answer 23

1 - L4-5 or L5-S1

Question 24

What are the 4 most common signs of cauda equina?

Answer 24

1 - bilateral sensory loss or weakness
2 - urinary retention
3 - loss of perineal sensation
4 - sexual dysfunction

Question 25

How long does it take normal back pain to alleviate?

1 - <6 days
2 - <6 weeks
3 - <6 months
4 - <1 year

Answer 25

2 - <6 weeks

Question 26

Yellow flags are commonly associated with beliefs about a problem, pain or injury. What are the 3 most common yellow flags in lower back pain?

1 - increased physical function, anxiety, passive negative attitude to pain
2 - poor physical function, anxiety, passive negative attitude to pain
3 - increased activity, high level of distress, passive negative attitude to pain
4 - poor physical function, high level of distress, passive negative attitude to pain

Answer 26

4 - poor physical function, high level of distress, passive negative attitude to pain