Low Back Pain and Sciatica Flashcards
What questions would you ask about character of back pain?
- Dull
- Stabbing
- Throbbing
- Burning
What questions would you ask about location and radiation of back pain?
Buttocks (muscle)
Below knee (maybe disc)
What questions would you ask about duration of back pain?
Acute vs subacute vs chronic
What associated symptoms of back pain need to be assessed?
Stiffness
Numbness/tingling
Urinary symptoms
What aggravating factors of back pain need to be assessed?
Certain positions (sitting)
Coughing
sneezing
Walking down the stairs
What relieving factors of back pain need to be assessed?
- Certain positions
- Non-pharmacological measures (massage, osteopath, acupuncture, PT)
- Analgesia
Describe a history for back pain?
Past medical history
History of PC
- onset
- character
- location and radiation
- duration
- intensity
- associated symptoms
Systems review
Medical and surgical history
Drug history
Family History
Social History
What systems reviews need to be done in a presentation of back pain?
- fever
- appetite/weight loss
- abdominal pain
- cough/haemoptysia
- dysuria/haemoturia
- menstrual history
What questions about medical and surgical history must be asked?
Trauma
Previous operations including spine
Malignancy
What questions about drug history must be asked?
Corticosteroids
Immunosuppressants
Anti-platelet
Anticoagulant
What questions about family history must be asked?
Cancers
Back pain/spondyloarthropathies
What questions about social history must be asked?
Job (type of work, ?physical, level of activity)
Smoking history
Recreational drug use
Sporting activities
What needs to be determined and ruled out in a patient with lower back pain?
Determine the pain is intrinsic from the back and not referred from elsewhere
Rule out life-threatening disease
Determine whether root compression is present
What are the general red flags of back pain?
- Failure to improve after 4-6 weeks of conservative therapy
- Unrelenting night pain or pain at rest
- Progressive motor or sensory deficit
What are the cancer red flags of back pain?
- Age > 50
- unintended weight loss
- history of cancer
- pain at night and in recumbency
What are the infection red flags of back pain?
- fever/chills
- recent infection
- immunosuppression
- IV drug use
- Dental status
- Foreign travel
What are the fracture red flags of back pain?
- age > 50
- osteoporosis
- significant trauma
- chronic steroid use
What are the cauda equina syndrome red flags for back pain?
- bilateral sciatica
- urinary incontinence
- leg weakness
- decreased anal tone
- Loss of perianal sensation
What are the AAA red flags of cauda equina syndrome?
- Age > 60
- Abdominal pulsating mass
- Pain at rest
Describe examination in back pain
- general appearance
- vital signs
- back examination
- GAIT
- heels
- tip toes
- LOOK: from side and back
- FEEL: SPs, steps, SI joints
- MOVE: flexion, extension, lateral bending, rotation
- GAIT
- other tests
- SLR
- muscle strength
- sensation
- deep tendon reflexes
Each joint movement consists of 4 consecutive spinal nerves;
Hip flexion ___and extension ___
Knee flexion ___ and extension ___
Ankle plantarflexion ____ and dorsiflexion ____
Foot inversion ___ and eversion ____.
Each joint movement consists of 4 consecutive spinal nerves;
Hip flexion L2,3 and extension L4,5
Knee flexion L5,S1 and extension L3,4
Ankle plantarflexion S1,2 and dorsiflexion L4,5
Foot inversion L4 and eversion L5,S1.
Describe the grading of muscle power
0- Complete paralysis
1- Flicker of contraction possible
2- Movement possible if gravity eliminated
3- movement against gravity but not against resistance
4- movement possible against some resistance
5- power normal (it is not normally possible to overcome a normal adult’s power)
Sensation across foot on both dorsal and plantar surfaces from medial to lateral is __-__-__
Sensation across foot on both dorsal and plantar surfaces from medial to lateral is L4-L5-S1
Myotome dance
Neck flexion: __
Side bending: __
Shoulder elevation: __
Shoulder abductinon: __
Elbow flexion, wrist extension: __
Elbow extension, wrist flexion: __
Thumb extension: __
Finger abdunction: __
T2-T12
Hip flexion, knee extension, ankle dorsiflexion: __,_,_
Ankle dorsiflextion, toe extension: __-_
Hip extension: __
Knee flexion: __
Myotome dance
Neck flexion: C2
Side bending: C3
Shoulder elevation: C4
Shoulder abductinon: C5
Elbow flexion, wrist extension: C6
Elbow extension, wrist flexion: C7
Thumb extension: C8
Finger abdunction: T1
T2-T12
Hip flexion, knee extension, ankle dorsiflexion: L2,3,4
Ankle dorsiflextion, toe extension: L4-5
Hip extension: S1
Knee flexion: S2
Which nerve roots are being compressed?
L4, L5, S1
What spinal nerves are responsible for
Triceps reflex:
Biceps reflex:
Patellar reflex:
Achilles reflex:
Triceps reflex: C7, C8
Biceps reflex: C5, C6
Patellar reflex: L2, L3, L4
Achilles reflex: S1
What investigations are done for non resolving back pain?
Radiology
- X-ray
- CT
- MRI
- Bone scan
- PET/SPECT
Lab
- FBC, U&E’S
- Inflammatory markers
When should x-rays be used?
NOT ROUTINELY
Young men: SI joint to exclude ank spon
Elderly: to exclude vertebral collapse, other fractures, malignancy
X-rays for deformity
CTs have a limited application in acute LBP without….
Red flags
What are CTs good for?
Bony pathology (trauma, tumours, infection)
Good: foreign bodies, implants
Spinal fusion planning
MRI contraindicated/not available
What is MRI good for?
Details of soft tissues (including tumours, infection)
Some sequences good for new fractures
Bone oedema/microfractures
Red flags –> ___
Neurological signs and symptoms –> ___
Red flags –> MRI
Neurological signs and symptoms –> MRI
What is a radionucleotide bone scan used for?
Increased bone turnover
-fractures, osteomyelitis, paget’s disease, ank spondlyitis
Metastases
Tumours
-Osteoid osteoma
What will PET scan show?
Increased uptake in high turnover areas
Which laboratory tests are indicated if red flags are present?
- malignancy (PSA, acid phosphatase, monoclonal bands)
- Infection
- Metabolic causes (alk phos, Ca2+, PO4, HLA B-27)
What non-pharmacological intervention is there?
- Explanation
- Re-assurance
- No bed rest
What are the pharmacological interventions for LBP?
- Regular analgesia, incl NSAIDS
- Improve mobility
- Facilitate exercise
- Opiates for severe pain
- Short term
- Breakthrough only
- TCAs
- Injections
What complementary and alternative medicine interventions are there?
- acupuncture
- chiropractor
- osteopath
- massages
- physiotherapy
When should LBP be investigated?
No improvement after 4-6 weeks
Red flags
When should LBP be referred?
- Intractable pain
- Serious pathology suspected or suggested on initial imaging
- Neurological deficit
What are the risk factors for LBP?
- previous back pain
- heavy lifting/frequent bending
- repetitive work with exposure to vibration
What are the best ways of preventing back pain?
- education
- lifting, turning
- mental coping strategies
- stop smoking
- physical activity
What is the treatment plan for sciatica?
Initially conservative
Unless red flags: surgical intervention
What is the DDx of sciatica?
- Root compression by other degenerative disease
- bone spurs, canal stenosis, spondylolisthesis, facet arthropathy
- Root compression of sinister causes
- (tumour, fractures, TB)
- Root compression outside the spine
- (piriformis syndrome, endometriosis, pelvic disease,peroneal compression…)
- No root compression
- (arachnoiditis, peripheral neuropathies)
What is piriformis syndrome?
Tight piriformis compresses sciatic nerve
