Lower back pain and sciatica Flashcards
What defines acute lower back pain?
Anything less than 6 weeks
What should be evaluated in someone with LBP?
Determine is pain is intrinsic and not referred from elsewhere; AAA
Rule out life threatening disease; in children screen for cancer
Determine whether root compression is present
General red flags in back pain?
Failure to improve after 4-6 weeks
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit
Cancer red flags
Age >50
Unintended wt loss
Hx of ca
Pain at night and in recumbency
Infection red flags
Fever/chills Recent infection Immunosuppression IVDU Dental status; 60-70% of brain and spinal abscesses have a dental origin Foreign travel
RF for #
Age >50
Osteoporosis
Significant trauma
Chronic steroid use
Sy for CES
Bilateral sciatica Urinary incontinence Leg weakness Absent anal tone Loss of perianal sensation; most sensitive indicator
Sy of AAA
Age >60
Male
Abdo pulsating mass
Pain at rest
LL neurological exam
SLR
Muscle strength
Sensation; light touch, pin prick, vibration
Deep tendon reflexes
Nerve root for flexion of hip
L2,3
Nerve root for extension of hip
L4,5
Nerve root for extension of knee
L3,4
Nerve root for flexion of knee
L5,S1
Nerve root fo plantarflexion
S1,2
Nerve root for dorsiflexion
L4,5
Nerve root for eversion
L4
Nerve root for inversion
L5,S1
Nerve root for shoulder abduction
C5
Nerve root for shoulder adduction
C6,7
Nerve root for elbow flexion
C5,6
Nerve root for elbow extension
C7,8
Nerve root for wrist flexion and extension
C6,7
Nerve root for finger abduction
C8,T1
Nerve root for finger flexion
C7,8
Nerve root for finger extension
C7,8
Nerve root for supination
C6
Nerve root for pronation
C7,8
When should you request an x-ray in LBP?
Young men; SI-joints to exclude ank spon
Elderly; exclude vertebral collapse, # or malignancy
What is a CT good for in terms of localisation of pathology of the spine?
Bony pathology; trauma, tumour, infection
Foreign bodies
Implants
Spinal fusion planning
What is an MRI good for in terms of localisation of spinal pathology?
Soft tissue; tumours, infection
Bone oedema
Can see spinal cord MUCH better
What modality of imagine should be used for spinal pathologies that have red flags or neurological si/sy?
MRI
What will radionucleotide scans show?
Increased bone turnover; #, osteomyelitis, paget’s, ank spon
Mets
Tumours; osteoid osteoma
When should lab tests be utilised in LBP?
Malignancy; PSA, acid phosphate, monoclonal bands
Infection
Metabolic; alk phos, calcium, phosphate, HLA B-27
When should LBP be investigated?
No improvement after 4-6 weeks
Red flags
When should LBP be referred to secondary care?
Intractable pain
Serious pathology suspected or suggested initial imaging
Neurological deficit
What are risk factors for back pain?
Previous back pain
Heavy lifting/ frequent bending
Repetitive work with exposure to vibration
What is the most effective preventative measure for back pain?
Exercise
What are differential diagnosis for sciatica?
Root compression by other degenerative disease: bony spurs, canal stenosis, spondylolisthesis, facet hypertrophy
Root compression of sinister cause: tumour, fracture, TB
Root compression from outwith the spine: piriformis syndrome, endometriosis, pelvic disease, peroneal compression (painless foot drop)
No root compression: arachnoiditis, peripheral neuropathy
What commonly causes an increase in pain with a disc prolapse?
Coughing
Sneezing
Twisting
What are the examination signs of a L5/S1 disc prolapse?
Reduced forward flexion and extension (all disc prolapses)
Calf pain
Weak foot plantar flexion
Reduced pin prick over sole of foot and back of cald
Reduced ankle jerk
Examination findings in an L4/L5 disc prolapse
Hallux extension weak
Reduced sensation on outer dorsum of foot
What causes CES?
Central prolapse of lumbar disc
When is a discectomy indicated?
CES
Progressive muscular weakness
Continuing pain
What is spondylolisthesis?
Displacement of one lumbar vertebrae on another usually L5 on S1
What can cause spondylothesis?
Spondylosis (age related degeneration with osteophyte formation)
Congenital malformation
OA of facet joints
What causes lumbar spinal stenosis and lateral recess stenosis?
Generalised narrowing of lumbar spinal canal or its lateral recesses causing nerve ischaemia
Facet joint OA and osteophytes
What are the symptoms of spinal stenosis and lateral recess stenosis?
Pain worse on walking
Pain on extension
Negative SLR
Few CNS signs
Yellow flags for back pain
Belief that pian and subsequent activity are harmeful
Pain behaviour
Over-reliance on passive treatments
Depression, anxiety, personality disorders
Unsupportive home environment or over-protective family
Inappropriate expectations and failing to actively engage with tx
Typical causes of back pain in those 15-30yrs?
Prolapsed disc Trauma # Ank spon Spondylolisthesis Pregnancy
Typical causes of back pain in those >30yrs?
Prolapsed disc
Malignancy (lung, breast, prostate, thyroid kidney)
Typical causes of back pain in those >50yrs?
Degenerative disc Osteoporosis Paget's Malignant Myeloma Lumbar artery atheroma
