Low Back Pain Flashcards
What are the red flags of low back pain?
Age > 50y or < 20y
Hx Ca
Temp > 37.8
Constant pain (day and night; worse at night)
Unexplained weight loss
Significant trauma
Features of spondyloarthropaty (e.g. peripheral arthritis - age < 40y, night waking)
Neurological deficit
Drug or alcohol abuse (inc IVDU)
Use of anticoagulants
Use of corticosteroids
No improvement > 1 mth
Possible cauda equina syndrome (saddle anaesthesia, recent onset of bladder dysfunction or overflow incontionence, bilateral or progressive neurological deficit)
Symptoms in other systems e.g. cough, breast mass
What are the yellow flags of low back pain?
Yellow flags = IDs psycho-social and occupational factors that increase the risk of chronicity in ppl presenting with acute back pain. Abnormal illness behaviour Compensation issues Unsatisfactory response to Rx Rx refused Atypical physical signs
What are the 5 main natures of the pain?
The nature of pain may reveal its origin:
- Aching, throbbing pain = inflammation (sacroiliitis)
- Deep aching diffuse pain = referred pain (dysmenorrhoea)
- Superficial steady diffuse pain = local pain (muscular strain)
- Boring deep pain = bone disease (neoplasia, Paget’s)
- Intense sharp or stabbing (superimposed on a dull ache) = radicular pain (sciatica)
What is continuous pain, present day and night suggestive of?
Neoplasia or infection
What is pain on waking suggestive of?
Inflammation or depression
What is pain that is worsened by rest, but relieved by activity suggestive of?
Inflammation
What is pain that is aggravated by standing or walking, and relieved by sitting suggestive of?
Spondylolisthesis
What is pain of the calf that travels proximally with walking suggestive of?
Vascular claudication
What is pain in the buttock that descends with walking suggestive of?
Neurogenic claudication
List key questions of low back pain.
- What is your general health like?
- Can you describe the nature of your back pain?
- Was your pain brought on by an injury?
- Is it worse when you wake in the morning or later in the day?
- How do you sleep during the night?
- What effect does rest have on pain?
- What effect does activity have on the pain?
- Is the pain worse when sitting or standing?
- What effect does coughing or sneezing or straining at toilet have?
- What happens to the pain in your back or leg if you go for a long walk?
- Do you have a Hx of psoriasis, diarrhoea, penile discharge, eye trouble or severe pain in your joints?
- Do you have any urinary symptoms?
- What medications are you taking? Are you corticosteroids? Are you on anti-coagulants?
- Are you under any extra stress at work or home?
- Do you feel tense or depressed or irritable?
What is neurogenic claudication?
Neuro = nerve
Claudication = painful cramping or weakness in legs
Common symptoms of lumbar spinal stenosis or inflammation of nerve roots.
Neurogenic claudication is relieved by changing position (not rest, cf vascular claudication)
What are the most probable diagnoses for low back pain?
- vertebral dysfunction especially facet joint and disc
- musculoligamentous strain/sprain
- spondylosis (degenerative OA)
What are the serious low back pain disorders that cannot be missed?
- CV:
a. ruptured aortic aneurysm
b. retroperitoneal haemorrahge (anticoagulants) - Neoplasia
a. myeloma
b. metastases - Severe infections
a. vertebral osteomyelitis
b. epidural abscess
c. septic discitis
d. TB
e. pelvic abscess/ PID - Osteoporotic compression fracture
- Cauda equina compression
The big three metastases are from the:
Breast, lungs and prostate (main three)
Other three: thyroid, kidney or adrenal, melanoma
The big primary malignancy is:
Multiple myeloma
In a young person with inflammation always think of:
ankylosing spondylitis
Stiffness at rest, pain with or after activity and relief with rest suggests:
OA
Pain in periphery of limb:
discogenic ->radicular or vascular -> claudication or spinal canal stenosis -> claudication
T/F One nerve root = one disc (usually)
T
T/F Two or more nerve roots, means that you should always consider neoplasm
T
What is the rule of thumb for lumbar nerve root lesions with spondylisthesis?
Lumbar nerve root lesions is L3 from L2-L3 disc L4 drom L3-4 disc L5 from L4-L5 disc S1 from L5-S1 disc
Severe limitation of SLR (especially less than 30 degrees) indicates what?
Lumbar disc prolapse
1
Upon inspection, what do midline moles, tufts of hair or haemangioma indicate?
Underlying congenital anomaly such as spina bifida occulta
What are the movements that should be tested and what are their normal ranges?
Extension (20-30 degrees)
Lateral flexion (L and R) (30 degrees)
Flexion (75 - 90 degrees)
The tops of the iliac crest lie at the level of?
L3-L4 interspace or L4 spinous process
What is the slump test and the significance of it?
Screening test for disc lesion and dural tethering. Should be performed on patients with low back pain with pain extending into leg (especially posterior thigh pain)
+ result = reproduction of pt’s pain
Method:
- Sit patient on couch, relaxed
- Patient then slumps forward (round the back)
- The unaffected leg is straightened
- The affected leg is only then straightened
- Both legs are straightened together
- The foot of the affected straightened leg is dorsiflexed
NB: deflexing the neck should relieve the pain of spina origin (not in hamstring pain origin)
When should a neurological examination be performed?
When the pt’s symptoms (e.g. pain, paraesthesia, aneasthesia and weakness) extends into the leg
(disc prolapse or tumour)
What does the neurological examination component of the Px of low back pain include?
- quick tests: walking on heels (L5), walking on toes (S1)
- dural stretch tests: slump test, straight leg raising
- specific nerve root tests (L4, L5, S1): sensation, power, reflexes
How do you test L3 (motor, sensation, reflex)?
Femoral stretch test (prone, flex knee, extend hip)
Motor - extension of knee
Sensation - anterior thigh
Reflex - knee jerk (L3, L4)
How do you test L4 (motor, sensation, reflex)?
Motor: resisted inversion foot
Sensation: inner border of foot to great toe
Reflex: knee jerk (L3, L4)
How do you test L5 (motor, sensation, reflex)?
Motor: walking on heels, resisted extension of great toe
Sensation: middle three toes (dorsum)
Reflex: nil
How do you test S1 (motor, sensation, reflex)?
Motor: walking on toes, resisted eversion foot
Sensation: little toe, most of sole
Reflex: ankle jerk (S1, S2)
