Low back Pain and Sciatica

Question 1

What are some important features of the history in a patient with lower back pain?

Answer 1

Character = dull, stabbing, throbbing, burning
Location/radiation = buttock (muscle) below knee (disc)
Duration and intensity

Question 2

What are some associated symptoms that a patient with lower back pain may have?

Answer 2

Stiffness, numbness, tingling, urinary symptoms

Question 3

What are some aggravating and relieving factors in a patient with lower back pain?

Answer 3

Aggravating = certain positions, coughing, sneezing, walking down stairs
Relieving = certain positions, analgesia, massage, osteopath, acupuncture

Question 4

What should be covered in a systemic enquiry in a patient with lower back pain?

Answer 4

Fever, appetite, weight loss, abdominal pain, cough, haemoptysis, dysuria, menstrual history

Question 5

What should you do when evaluating a patient with lower back pain?

Answer 5

Determine that pain is intrinsic from back and not referred from elsewhere
Rule out life threatening disease
Determine whether root compression is present

Question 6

What are some general red flags in a patient with lower back pain?

Answer 6

Failure to improve after 4-6 weeks conservative therapy
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit

Question 7

What are some red flags that would make you suspect cancer in a patient with lower back pain?

Answer 7

Age >50, weight loss and history of cancer

Pain at night and in recumbency

Question 8

What are some red flags that would make you suspect infection in a patient with lower back pain?

Answer 8

Fever or chills, recent infection, immunosuppression, IV drug user, foreign travel, poor dental health

Question 9

What are some red flags that would indicate a patient with lower back pain has a fracture?

Answer 9

Age >50, osteoporosis, significant trauma, chronic steroid use

Question 10

What are some red flags for cauda equina syndrome?

Answer 10

Bilateral sciatica, urinary incontinence, leg weakness, decreased anal tone, loss of perianal sensation

Question 11

What are some red flags for an abdominal aortic aneurysm in a patient with lower back pain?

Answer 11

Age >60, abdominal pulsating mass, pain at rest

Question 12

What are some features of the examination of a patient with lower back pain?

Answer 12

General appearance and vital signs
Back examination
Other tests = straight leg raise, muscle strength, sensation, deep tendon reflexes

Question 13

What should be covered in a back examination?

Answer 13

Gait, look from side and back, feel SPs and SI joints

Assess flexion, extension, lateral bending and rotation

Question 14

How is muscle power graded?

Answer 14

0 = complete paralysis
1 = flicker of contraction possible
2 = movement possible if gravity eliminated
3 = movement against gravity but not resistance

Question 15

Do you need to do investigations in patients with acute lower back pain?

Answer 15

Not in most = 70-90% will resolve within a month

Question 16

When would you do a plain x-ray?

Answer 16

In young men to rule out ankylosing spondylitis

In elderly to exclude vertebral collapse or malignancy

Question 17

What are the negatives of doing an x-ray?

Answer 17

Not very sensitive or specific

Doesn’t rule out serious illness or show soft tissue

Question 18

When would you do a CT scan?

Answer 18

Bony pathology, foreign bodies, spinal fusion planning or if MRI contraindicated

Question 19

When are MRI scans useful?

Answer 19

Do if red flags or neurological signs present
Provides details of soft tissues
Some sequences good for new fractures and bone oedema

Question 20

What do radionucleotide bone scans show?

Answer 20

Increased bone turnover = fractures, Paget’s, osteomyelitis, ankylosing spondylitis
Metastases, tumours and osteoid oedema

Question 21

What do PET scans show?

Answer 21

Increased uptake in high turnover areas

Question 22

When would you do lab tests in a patient with lower back pain?

Answer 22

If red flags present = PSA or monoclonal bands for malignancy, alk phos and Ca2+ for metabolic causes, infection screening

Question 23

What imaging can be done for lower back pain?

Answer 23

X-rays, CT scans, MRI, radionucleotide bone scans, PET scan

Question 24

What is the pharmacological treatment of lower back pain?

Answer 24

Regular analgesia = improve mobility and facilitate exercise
Opiates for severe pain = short term use for breakthrough only

Question 25

What are some complementary medicine options for treating lower back pain?

Answer 25

Acupuncture, chiropractor, osteopath, massages, physiotherapy

Question 26

When would you refer a patient with lower back pain?

Answer 26

Intractable pain, serious pathology suspected or suggested on initial imaging, neurological deficit

Question 27

What are some differentials for lower back pain?

Answer 27

Degenerative disease, malignancy, TB, root compression outside of spine, arachnoiditis, peripheral neuropathies, fractures

Question 28

What are some degenerative diseases that may cause root compression?

Answer 28

Bone spurs, canal stenosis, spondylolisthesis, facet arthropathy

Question 29

What are some causes of root compression outside of the spine?

Answer 29

Piriformis syndrome, endometriosis, pelvic disease, peroneal compression

Question 30

What is piriformis syndrome?

Answer 30

Muscles spasms = cause buttocks pain, can irritate sciatic nerve causing pain along the bac of the leg and into the foot