Low back pain (LBP)

Question 1

What are the common causes?

Answer 1

1) Dysfunction of the spinal intervertebral joints (mechanical back pain or non-specific back pain) due to injury ~72%
2) lumbar spondylosis (degenerative osteoarthritis) ~10%
3) Musculoligamentous strain is common but usually settles in days

Question 2

What are the serious disorders not to be missed?

Answer 2

Vascular

• ruptured aortic aneurysm
• retroperitoneal haemorrhage (anticoagulants)

Infection

• osteomyelitis
• epidural abscess
• septic discitis
• tuberculosis
• pelvic abscess/PID
• pyelonephritis

Cancer

• pancreas
• myeloma
• metastases

Cauda equina compression

Osteoporotic compression fracture

Question 3

What are the red flag pointers for back pain?

Answer 3

• age >50 years or <20 years
• history of cancer
• temperature >37.8°C; night sweats
• constant pain—day and night
• unexplained weight loss
• significant trauma (e.g. MVA)
• osteoporosis ♀ >50 years; ♂ >60 years
• use of anticoagulants and corticosteroids
• drug or alcohol abuse esp. IV drug use
• no improvement over 1 month
• neurological deficit
• possible cauda equina syndrome

Question 4

Pitfalls (often missed)?

Answer 4

1) Spondyloarthropathies
• ankylosing spondylitis
• reactive arthritis
• psoriasis
• bowel inflammation
2) Sacroiliac dysfunction
3) Spondylolisthesis
4) Claudication
• vascular
• neurogenic/spinal canal stenosis
5) Prostatitis
6) Endometriosis

Question 5

Masquerades? تنكر

Answer 5

1. Depression
2. Spinal dysfunction
3. UTI

Question 6

Is this patient trying to tell me something?

Answer 6

1. Quite likely many yellow flags
2. Consider lifestyle
3. Stress
4. Work problems
5. Malingering تمارض
6. Conversion reaction;
   A disorder in which a person experiences blindness, paralysis, or other symptoms affecting the nervous system that cannot be explained solely by a physical illness or injury.
   Symptoms usually begin suddenly after a period of emotional or physical distress or psychological conflict.

Question 7

Clinical key examination

Answer 7

1. LOOK, FEEL, MOVE,MEASURE
2. Emphasis on palpation—central and lateral
3. The movements of the lumbosacral spine with normal ranges are:
   •extension 20°–30°
   •forward flexion 75°–90°
   •lateral flexion (left and right) 30°
4. Perform a neurological and vascular
   examination of the lower limb/s if pain.

Question 8

Key investigation

Answer 8

This should be conservative, especially in the absence of red flags.
•FBE
•ESR/CRP
•urinalysis
•serum alkaline phosphatase
•PSA in males 50–69 years
•plain X-ray if chronic pain and red flags
Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).

Question 9

Continuous pain (day and night) means

Answer 9

Malignancy or infection

Question 10

What is the the big primary malignancy ?

Answer 10

Multiple Myeloma

Question 11

What are the big 3 metastases ?

Answer 11

lung, breast and prostate

Question 12

What are the other 3 metastases?

Answer 12

thyroid, kidney/adrenal and melanoma

Question 13

Pain with standing/walking (relief with sitting) =

Answer 13

spondylolisthesis

Question 14

Pain (and stiffness) at rest, relief with activity =

Answer 14

inflammation

Question 15

In a young person with inflammation think of =

Answer 15

ankylosing spondylitis, Reiter syndrome or reactive arthritis.

Question 16

Stiffness at rest, pain with or after activity, relief with rest =

Answer 16

osteoarthritis

Question 17

Pain provoked by activity, relief with rest =

Answer 17

mechanical dysfunction

Question 18

Pain in bed at early morning =

Answer 18

inflammation, depression or malignancy/infection.

Question 19

Pain in periphery of limb =

Answer 19

discogenic → radicular
or vascular → claudication
or spinal canal stenosis → claudication.

Question 20

Pain in calf (ascending) with walking =

Answer 20

vascular claudication.

Question 21

Pain in buttock (descending) with walking =

Answer 21

neurogenic claudication

Question 22

One disc lesion = one nerve root (exception is L5–S1 disc). One nerve root =

Answer 22

one disc (usu.)

Question 23

Two or more nerve roots—consider

Answer 23

neoplasm

Question 24

The rule of thumb for the lumbar nerve root lesions is

Answer 24

L3 from L2–3 disc
L4 from L3–4
L5 from L4–5
S1 from L5–S1

Question 25

A large disc protrusion can cause

Answer 25

bladder symptoms, either incontinence or retention

Question 26

A retroperitoneal bleed from anticoagulation therapy can give

Answer 26

intense nerve root symptoms and signs.