Low Back Pain & Sciatica Flashcards
What should you ask a patient about onset of their back pain when taking a history?
- Was it sudden?
- Have you noticed a trigger?
How may a patient describe the character of their back pain?
- Dull
- Stabbing
Location and radiation of back pain is an indicator for the cause. TRUE/FALSE?
TRUE
e.g. if radiates to buttocks = muscular pain
If radiates to knee = more likely nerve pain
After how many months would back pain be considered chronic?
> 3 months
How should you ask about the intensity of a patients back pain (without using the 1-10 severity scale)?
Ask about what tasks it prohibits them from doing that they could do previously
e.g. climbing stairs
What associated symptoms should you always ask about in patients with back pain?
Urinary symptoms faecal symptoms (e.g. incontinence of both)
What factors can potentially aggravate patients back pain?
- certain positions
- coughing, sneezing (increases intrathecal pressure on nerve roots)
- walking down stairs (due to walking on heel first)
What factors can relieve a persons back pain?
- certain positions i.e. lying and standing usually better than sitting
- non-pharmacological methods - physio chiropractor
- analgesia
What should be asked about in the systems review to check for causes other than mechanical back pain?
fever weight loss abdominal pain cough/haemoptysis dysuria/haematuria
What parts of a PMHx (including surgery) should you specifically ask about when a patient has back pain?
- previous trauma
- previous operations e.g. on spine
- previous malignancy
What parts of the social history are important when patients present with back pain?
- Occupation (type of work, level of activity during)
- Smoking
- Recreational drugs (e.g. steroids)
Back pain can be referred from elsewhere. TRUE/FALSE?
TRUE
=> always check that a patient’s back pain is not referred pain
What are the MAIN red flags of back pain?
- Pain at night OR at rest
- Failure of pain to improve after 4-6 weeks of conservative therapy
- Motor or sensory deficit
What red flags of back pain and other risk factors may indicate cancer?
> 50 years old
unintentional weight loss
previous history of cancer
Night pain
What symptoms and risk factors would indicate back pain is due to an infection?
- Fever/chills
- Recent infection
- Immunosuppression
- IV drug use
- Dental Status
- Foreign Travel
What symptoms and risk factors would make you consider that a patients back pain is due to a fracture?
> 50 years old
osteoporosis (particularly females)
trauma
chronic steroid use
What symptoms and risk factors indicate ower back pain is due to sciatica?
- bilateral sciatica
- urinary incontinence
- leg weakness
- Impaired anal tone
- loss of perianal sensation
What signs and symptoms may indicate an AAA causing lower back pain?
> 60 years old
pulsating mass
pain at rest
What other tests should be completed alongside a spinal examination?
Straight leg raise (testing hips) Test muscle strength Test sensation Deep tendon reflexes Standing on heels and then toes (whilst supported) Lower limb assessment
Investigations are often not required in patients with lower back pain. TRUE/FALSE?
TRUE
70-90% don’t require investigating as it will resolve with analgesia and activity
Who should we X-Ray when they complain of back pain?
Young men - check SI joints for ankylosing spondylitis
Elderly patients - vertebral collapse, fracture, malignancy
When is CT used to investigate back pain?
Limited use UNLESS RED FLAGS
=> looks for bone pathology- tumour, infection, trauma
Useful if MRI contraindicated
When is MRI used to investigate back pain?
- visualise soft tissue
- If suspicious of a new fracture/ microfractures
- shows bony oedema
- *IF RED FLAGS USE MRI FIRST THEN CT**
What is a radionuclide bone scan used to investigate in back pain?
- Shows increased bone turnover (e.g. Pagets disease, Ankylosing Spondylitis)
- Shows Tumours and metastases as these have increased cell turnover
Why is a PET scan used in back pain investigation?
Increased uptake in areas of high turnover
- closest modality we currently have to imaging areas of pain
What are lab tests used for in the context of back pain?
Rule out malignancy and infection
What non-pharmacological treatments are used in back pain?
- Explain/educate
- reassure most is self-limiting
- advice on activity/exercise
What simple analgesia is often used in back pain management?
NSAIDs (useful for MSK pain, but unsuitable for many patients)
Opioids for breakthrough pain
What Injections can provide relief in back pain?
Facet joint injections
Epidural blocks
What complementary/alternative therapy is sometimes used in back pain?
acupuncture chiropractor osteopath massage PHYSIO
When should you begin to investigate a patient with back pain?
If no improvement after 4-6 weeks of conservative management
When should back pain be referred?
intractable pain
serious pathology suspected
neurological deficit
What are the risk factors for mechanical back pain?
Previous episode of back pain
heavy lifting / frequent bending
repetitive work
exposure to vibration (construction work)
How can back pain be prevented?
Education on lifting/turning with heavy objects
Mental coping strategies for pain
Smoking cessation
Other than mechnical back pain, what differentials could be causing a patients back pain?
Root compression due to degenerative disease
Sinister causes (Tumour, TB)
Compression outside of spine (e.g. endometriosis)
No root compression (peripheral neuropathy)
What is piriformis syndrome and what nerve does it affect?
Condition where sciatic nerve runs WITHIN piriformis muscle
=> when muscle contracts patient experiences sciatic pain
Sciatica is generally self-limting. TRUE/FALSE?
TRUE
