Lower Back Pain

Question 1

Lower Back Pain:

Red flags?

Answer 1

Symptoms suggestive of:
Cancer
-new pain and past cancer
-unintended weight loss
-nocturnal pain
-not improved after 4 weeks

Vertebral infection

• fever
• recent IV drug use
• immunocompromised
• rest pain

Cauda Equina

• urinary retention
• faecal incontinence
• saddle anaesthesia
• lower limb weakness

Fracture

• Osteoporosis
• recent fall/trauma

Ankylosing Spondylitis

• morning stiffness
• stiffness relieved with movement
• alternating buttock pain
• pain on waking in the second half of the night

Question 2

Lower Back Pain:

Approach to diagnosis?

Answer 2

1) Could it be non spinal back pain? (hip, visceral, pelvic pathology, vascular)
2) Which category does the back pain fit in?

a) Specific spinal pathology <1% = red flags (vertebral fracture, spinal infection, cauda equina, malignancy, ankylosing spondylitis)
b) radicular syndromes
c) non specific lower back pain

Question 3

Lower Back Pain:

How to think about radicular syndromes?

Answer 3

Different types of lumbosacral nerve root involvement

1) Radicular pain
2) Radiculopathy
3) Spinal stenosis

Question 4

Lower Back Pain:

Pathophysiology of lumbosacral nerve root syndromes (radicular syndromes)?

Answer 4

• disc herniation
• osteophytes
• facet joint cysts
• spondylolithesis
• acquired or congenital canal stenosis

Question 5

Lower Back Pain:

How to differentiate radicular syndromes?

Answer 5

1) Radicular pain
- leg pain 60%
- specific dermatomal dominant pain below the knee L4, L5, S1
- positive nerve tension test (either prone knee bend or straight leg raise)

2) Radiculopathy (may have pain AND the following)
- dermatomal sensory disturbance distal to knee
- myotomal muscle weakness (eg foot drop)
- hypoactive reflexes (knee jerk L3/4 or ankle jerk L5/S1)

3) Spinal stenosis
- neurogenic claudication relieved by flexing forward or sitting
- stooped posture
- wide based gait
- neurological exam often normal

Question 6

Lower Back Pain:

Stepwise approach to lower back pain?

Answer 6

only image if red flags, suspected spinal stenosis, radiculopathy that does not improve after 6 weeks or there is progressive neurological deficit

• *Common radiological findings in pain free patients
• degeneration 91%
• disc bulges 56%
• annular tears 38%
• protrusion 32%

Radicular syndromes

• conservative management with physiotherapy education and flexion biased conditioning exercises has similar outcomes to decompressive surgery
• Surgery reserved for radicular syndrome that are progressing or not resolving

Non specific lower back pain

• *optimise
• comorbidities
• sleep
• mental health
• social roles

Education about pain and factors that increase or decrease its experience

Screen them with the STarT Back Screening Tool (http://www.agencymeddirectors.wa.gov/Files/AssessmentTools/5-Keele_STarT_Back9_item-7.pdf) to categorise their risk and stepwise management.
Low = as below
Medium = Physiotherapy course
High = CBT trained physiotherapy

1) Reassure benign cause and that recovery typically takes 2 weeks to start

2) Pain management
a) normal activity + 1g paracetamol four times per day + heat = review in 1 - 2 weeks
b) add in NSAIDS, opioids = review 1 - 2 weeks
c) start exercise - ideally supervised use of back muscles is required to maintain strength