Low back pain Flashcards
What is the time-frame marker separating acute/chronic back pain?
3 months
What is the percentage of non-specific lower back pain out of all lower back pain that present to primary care?
90-95%
Non-specific = without a single underlying cause, usually mechanical
Drug treatment for symptom relief in non-specific back pain?
1st line - NSAIDS
2nd line - Short-term use of codeine w/ or w/o paracetamol
List all the uncommon but red-flag conditions to screen for in low back pain.
Cauda Equina syndrome
Cancer
Spinal fracture
Infection
Symptoms in cauda equina syndrome.
- Sudden-onset bilateral radicular leg pain or unilateral radicular pain progressing to bilateral pain; severe or progressive neurological deficit such as major motor weakness of knee extension, ankle eversion, or foot dorsiflexion.
- Recent-onset difficulty initiating micturition or impaired sensation of urinary flow; urinary retention and/or overflow urinary incontinence (late signs).
- Recent-onset loss of sensation of rectal fullness; faecal incontinence (late sign).
- Recent-onset erectile dysfunction or sexual dysfunction.
- Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
- Unexpected laxity of the anal sphincter.
- Gait disturbance or difficulty walking.
Symptoms in spinal fracture
- Sudden onset of severe central spinal pain which is relieved by lying down.
- A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis.
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra).
- Point tenderness over a vertebral body.
Symptoms in cancer related to this presentation.
Age 50 years or over.
Gradual onset of symptoms or progressive pain.
Severe unremitting lumbar pain; thoracic back pain; night spinal pain preventing sleep; spinal pain aggravated by straining (for example coughing, sneezing, or defaecation).
Localised spinal tenderness.
Mechanical pain (aggravated by standing, sitting or moving).
No symptomatic improvement after 4–6 weeks of conservative treatment.
Unexplained weight loss.
Claudication (muscle pain or cramping in legs when walking or exercising).
Past history of cancer (breast, lung, prostate, renal, and gastric cancer are more likely to metastasize to the spine).
Symptoms of infection (such as discitis, vertebral osteomyelitis, spinal or epidural abscess)
Fever; systemically unwell.
Recent infection.
Diabetes mellitus.
History of intravenous drug use.
HIV infection, use of immunosuppressant drugs, or other cause of immunocompromise.
List some neurological differentials for lower back pain.
What does night pain point towards?
cancer
How to perform a straight leg raise test and what does a positive test suggest?
With patient lying supine, raise one leg ensuring extension of knee, observe patient reaction and ask if the familiar pain is reproduced. (this can be amplified by ankle dorsiflexion or neck flexion)
Lumbar radiculopathy
Which nerve innervates the extensor hallucis longus and which spinal nerve roots does it arise from?
Deep fibular nerve
L5, S1
Which nerve supplies sensation of big/second/third toe & medial side of fourth toe and which spinal nerve roots does it arise from?
Medial plantar nerve (a branch of tibial nerve)
The tibial nerve arises from L4-S3
Go review lower limb dermatome!
What do you do when you suspect cauda equina syndrome?
Carry out a digital PR exam, once confirmed, send for an MRI lumbosacral spine, followed by surgery soon after
What clinical features point towards cauda equina syndrome as a diagnosis?
Bilateral sciatica
Severe / progressive neurological deficit
Painless urinary retention/ incontinence / bowel incontinence
Saddle anaesthesia
Loss of anal tone
