Lower Back Pain Flashcards
What are the red flags for lower back pain?
- Age < 20 years or > 50 years
- History of previous malignancy
- Night pain
- History of trauma
- Systemically unwell e.g. weight loss, fever
Describe the history of back pain due to facet joint arthritis?
May be acute or chronic.
Pain worse in the morning and on standing.
On examination there may be pain over the facets.
The pain is typically worse on extension of the back.
Describe the history of back pain due to spinal stenosis what examination is required?
- Usually gradual onset
- Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
- Relieved by sitting down, leaning forwards and crouching down
- Clinical examination is often normal
- Requires MRI to confirm diagnosis
Describe the history of back pain due to ankylosing spondylitis.
- Typically a young man who presents with lower back pain and stiffness
- Stiffness is usually worse in morning and improves with activity
- Peripheral arthritis (25%, more common if female)
Describe the history of back pain due to peripheral arterial disease.
- Pain on walking, relieved by rest
- Absent or weak foot pulses and other signs of limb ischaemia
- Past history may include smoking and other vascular diseases
What are the common presenting features of cauda equina?
- Urinary retention (50-70%)
- Lower limb motor weakness and sensory deficits - usually asymmetrical with loss of reflexes.
- Bowel and bladder dysfunction with saddle and perineal anaesthesia.
- Urinary dysfunction - retention, overflow incontinence, decrease sensation.
- Bowel disturbances - faecal incontinence, constipation. Loss of anal tone and sensation.
- Sexual dysfunction.
If there is a compression of the L3 nerve root, what would the clinical features be?
- Sensory loss over anterior thigh
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
If there is a compression of the L4 nerve root, what would the clinical features be?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
If there is a compression of the L5 nerve root, what would the clinical features be?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
If there is a compression of the S1 nerve root, what would the clinical features be?
- Sensory loss posterolateral aspect of leg and lateral aspect of foot
- Weakness in plantar flexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
The 2009 NICE Lower back pain guidance applies to what population group?
Non-specific lower back pain that has lasted for more than 6 weeks and less than 12 months.
What advice should be given to people with non-specific lower back pain?
- Encourage self-management
- Stay physically active and exercise.
What analgesia should be given to someone with non-specific lower back pain?
- First line: Paracetamol
- Co-prescribe PPI if >45 years if NSAID given.
- Second line: TCI (Amitryptiline)
- Short term use: Opioids
What non-medication treatment should be offered?
- Exercise programme - PT
- Manual therapy- osteopath or chiropractic
- Acupuncture
What investigations should be done on someone with nonspecific lower back pain?
None usually.
L-spine xray should not be offered.
MRI should only be considered when a specific cause is suspected (malignancy, infection, fracture, cauda equina or ank spond) or spinal fusion is being considered.
