Low back Pain and Sciatica Flashcards
What are some important features of the history in a patient with lower back pain?
Character = dull, stabbing, throbbing, burning
Location/radiation = buttock (muscle) below knee (disc)
Duration and intensity
What are some associated symptoms that a patient with lower back pain may have?
Stiffness, numbness, tingling, urinary symptoms
What are some aggravating and relieving factors in a patient with lower back pain?
Aggravating = certain positions, coughing, sneezing, walking down stairs Relieving = certain positions, analgesia, massage, osteopath, acupuncture
What should be covered in a systemic enquiry in a patient with lower back pain?
Fever, appetite, weight loss, abdominal pain, cough, haemoptysis, dysuria, menstrual history
What should you do when evaluating a patient with lower back pain?
Determine that pain is intrinsic from back and not referred from elsewhere
Rule out life threatening disease
Determine whether root compression is present
What are some general red flags in a patient with lower back pain?
Failure to improve after 4-6 weeks conservative therapy
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit
What are some red flags that would make you suspect cancer in a patient with lower back pain?
Age >50, weight loss and history of cancer
Pain at night and in recumbency
What are some red flags that would make you suspect infection in a patient with lower back pain?
Fever or chills, recent infection, immunosuppression, IV drug user, foreign travel, poor dental health
What are some red flags that would indicate a patient with lower back pain has a fracture?
Age >50, osteoporosis, significant trauma, chronic steroid use
What are some red flags for cauda equina syndrome?
Bilateral sciatica, urinary incontinence, leg weakness, decreased anal tone, loss of perianal sensation
What are some red flags for an abdominal aortic aneurysm in a patient with lower back pain?
Age >60, abdominal pulsating mass, pain at rest
What are some features of the examination of a patient with lower back pain?
General appearance and vital signs
Back examination
Other tests = straight leg raise, muscle strength, sensation, deep tendon reflexes
What should be covered in a back examination?
Gait, look from side and back, feel SPs and SI joints
Assess flexion, extension, lateral bending and rotation
How is muscle power graded?
0 = complete paralysis 1 = flicker of contraction possible 2 = movement possible if gravity eliminated 3 = movement against gravity but not resistance
Do you need to do investigations in patients with acute lower back pain?
Not in most = 70-90% will resolve within a month
When would you do a plain x-ray?
In young men to rule out ankylosing spondylitis
In elderly to exclude vertebral collapse or malignancy
What are the negatives of doing an x-ray?
Not very sensitive or specific
Doesn’t rule out serious illness or show soft tissue
When would you do a CT scan?
Bony pathology, foreign bodies, spinal fusion planning or if MRI contraindicated
When are MRI scans useful?
Do if red flags or neurological signs present
Provides details of soft tissues
Some sequences good for new fractures and bone oedema
What do radionucleotide bone scans show?
Increased bone turnover = fractures, Paget’s, osteomyelitis, ankylosing spondylitis
Metastases, tumours and osteoid oedema
What do PET scans show?
Increased uptake in high turnover areas
When would you do lab tests in a patient with lower back pain?
If red flags present = PSA or monoclonal bands for malignancy, alk phos and Ca2+ for metabolic causes, infection screening
What imaging can be done for lower back pain?
X-rays, CT scans, MRI, radionucleotide bone scans, PET scan
What is the pharmacological treatment of lower back pain?
Regular analgesia = improve mobility and facilitate exercise
Opiates for severe pain = short term use for breakthrough only
What are some complementary medicine options for treating lower back pain?
Acupuncture, chiropractor, osteopath, massages, physiotherapy
When would you refer a patient with lower back pain?
Intractable pain, serious pathology suspected or suggested on initial imaging, neurological deficit
What are some differentials for lower back pain?
Degenerative disease, malignancy, TB, root compression outside of spine, arachnoiditis, peripheral neuropathies, fractures
What are some degenerative diseases that may cause root compression?
Bone spurs, canal stenosis, spondylolisthesis, facet arthropathy
What are some causes of root compression outside of the spine?
Piriformis syndrome, endometriosis, pelvic disease, peroneal compression
What is piriformis syndrome?
Muscles spasms = cause buttocks pain, can irritate sciatic nerve causing pain along the bac of the leg and into the foot
