Low Back Pain

Question 1

What percentage of acute low back pain patients recover in 6 weeks?

Answer 1

90%

Question 2

What percentage of people are fully recovered from an episode of acute low back pain after 3 months?

Answer 2

21%

Question 3

Describe the difference in effect on the patient of pain of sudden onset vs. pain of gradual onset.

Answer 3

• Pain of sudden onset = greater disability in the short term.
• Pain of gradual onset = greater correlation with psychological symptoms.

Question 4

List 10 sources of spinal pain.

Answer 4

1. Intervertebral disc and endplates
2. Ligaments and capsule
3. Zygapophyseal joints
4. Bone
5. Periosteum, fascia, muscle, tendons and aponeurosis
6. Arteries and arterioles
7. Epidural and paravertebral veins
8. Dura
9. Nerve root sleeve
10. Nerve root and associated nerves

Question 5

Explain what the surgical seive is.

Answer 5

Vascular

Accident & trauma

Neoplastic / neurological

Inflammatory

Septic

Haematological / hereditary

Endocrinological

Degenerative

Question 6

What are the muskuloskeletal red flags of back pain?

Answer 6

• Cauda equina syndrome
• Infection / sepsis
• Neoplasm (benign or malignant)
• Trauma

Question 7

What is the clinical presentation of cauda equina syndrome?

Answer 7

• Difficulty with micturition
• Loss of anal sphincter tone or faecal incontinence
• Saddle anaesthesia about the anus, perineum or genitals
• Widespread (>1 nerve root) or progressive motor weakness in the legs or gait disturbance

Question 8

What are the indicators of possible serious pathology associated with low back pain?

Answer 8

• Age of onset <20 or >55 years
• RTC
• Thoracic pain
• Systemic steroids
• Systemically unwell
• Persisting severe restriction of lumbar flexion
• Structural deformity
• Voilent trauma
• Constant, progressive, non-mechanical pain
• PMH - carcinoma
• Drug abuse or PMH of HIV
• Unexplained weight loss
• Widespread neurology
• Widespread deformity

Question 9

What percentage of low back pain is simple mechanical backache?

Answer 9

85-95%

Question 10

What percentage of low back pain is nerve root associated?

Answer 10

5%

Question 11

What percentage of low back pain is associated with possible serious pathology?

Answer 11

1-2%

Question 12

What are the key questions which should be asked of a patient who presents with chronic low back pain?

Answer 12

• Have you had tie off work with your back pain?
• What do you think is causing your back pain?
• What do you think will help you? (Active or passive treatments)
• How are your employers, family and fellow employees reacting to your back pain?
• How are you coping with your back? (Active or passive)
• Do you think you will return to your present job? When?

Question 13

What are the characteristics of radicular (nerve root) pain?

Answer 13

• Unilateral leg pain leading to back pain
• Pain generally radiating to foot or toes
• Numbness and paraesthesia in the same distribution
• Nerve irritation signs
  
  • Reduced straight leg raise which reproduced leg pain
• Motor, sensory or reflex change
  
  • Limited to 1 nerve root
• Prognosis is reasonable
  
  • 50% recover from acute attack within 6 weeks

Question 14

Where would S1 root pain manifest?

Answer 14

Question 15

Where would L5 root pain manifest?

Answer 15

Question 16

Where would L4 root pain manifest?

Answer 16

Question 17

Where would L3 root pain manifest?

Answer 17

Question 18

What are the common features of spinal stenosis?

Answer 18

• Typically progresses slowly.
• Increased back and leg pain with walking (neurogenic claudication).
• Relieved with flexion postures.
• Pain on extension.
• Muscle strength and sensation can be intact.
• Decreased or absent ankle jerk reflex bilaterally.
• In most cases the symptoms remain unchanged or with little variation over the years (60-70%).
• There are also a few people who report that their condition improves with time. These people are able to walk further (15-20%).
• Around 15-20% of peollple find their condition gets worse. Over time they find that the distance they can walk gets less and less.

Question 19

Describe the characteristics of ‘mechanical, simple, non-specific, persistent’ low back pain?

Answer 19

• Age of onset generally 20-55
• Lumbosacral region, buttocks and thighs
• Pain ‘mechanical’ in nature
  
  • Varies with physical activity
  • Varies with time
• Patient is generally well
• Prognosis is good
  
  • ~90% recover from acute attack within 6 weeks

Question 20

Describe the characteristics of nociceptive low back pain.

Answer 20

• Usually intermittent and sharp with movement/mechanical provocation: may be a more constant dull ache or throb at rest.
• Pain localised to the area or injury/dysfunction with/without some somatic referral.
• Clear proportionate mechanical / anatomic nature to aggravating and easing factors.
• Absence of:
  
  • Pain variously described as burning, shooting, sharp or electric shock-like.
  • Pain in association with other dyaesthesia.
  • Night pain / disturbed sleep
  • Antalgic (pain relieving) postures / movement patterns.

Question 21

Describe the characteristics of peripheral neuropathic low back pain.

Answer 21

• History of nerve injury, pathology or mechanical compromise.
• Pain referred in a dermatomal or cutaneous distribution.
• Pain/symptom provocation with mechanical/movement tests that move/load.compress neural tissue.

Question 22

Describe the characteristics of central (sensitisation) low back pain.

Answer 22

• Pain disproportionate to the nature and extent of injury or pathology.
• Disproportionate non-mechanical unpredictable pattern of pain.
• Provocation in response to multiple/non-specific aggravating/easing factors.
• Strong association with maladaptive psychosocial factors e.g. negative emotions, poor self-efficacy maladaptive beliefs and pain-behaviours, altered family/work/social life, medical conflict.
• Diffuse/non-anatomicareas of pain/tenderness on palpation.