Lower back pain and sciatica

Question 1

What is mechanical back pain?

Answer 1

• pain arises from the spinal joints, vertebrae or soft tissues and is exacerbated by movement

Question 2

What are the 2 classifications of LBP?

Answer 2

• Acute (< 6weeks)
• Chronic (> 6weeks)

Question 3

What are the causes of lower back pain?

Answer 3

• Nonspecific low back pain (most common)
• Intervertebral disc prolapse
• vertebral fracture
• facet joint injury
• ankylosing spondylitis

Question 4

What is the peak age group for low back pain?

Answer 4

• 41-50 yo

Question 5

What are the RF of LBP?

Answer 5

• Highly demanding jobs
• prolonged standing
• awkward lifting
• obesity
• FHx

Question 6

What questions would you include when taking Hx of LBP?

Answer 6

• when the pain started
• pain was sudden or gradual in onset.
• location of the pain.
• pain radiation to anywhere else.
• aggravating or relieving factors.
• Confirming whether the patient has had this problem previously.
• Noting the patient’s occupation, hobbies or sport.
• confirm what they think caused the pain.
• Noting past medical history.
  
  • Steroid use predisposes to osteoporosis.
  • Establish whether there has been malignancy that metastasises to bone (lung, breast, prostate, thyroid, kidney) or myeloma.
• Asking the patient how they have been managing the condition

Question 7

How would you examine LBP?

Answer 7

• Preparation
  
  • Undress
  • Expose spine
  • Have patient standing
• Examination
  
  • inspection
  • palpation
  • brief neurological examination
  • assessment of function
• Assess red flags
  
  • Cauda equina syndrome
  • Spinal #
  • Cancer/infection

Question 8

What are the red flags for CES?

Answer 8

• Saddle anaesthesia
• Recent onset of bladder dysfunction.
• Recent onset of faecal incontinence.
• Perianal/perineal sensory loss.
• Unexpected laxity of the anal sphincter.
• Severe or progressive neurological deficit in the lower extremities.

Question 9

What are the red flag sx for spinal #?

Answer 9

• Sudden onset of severe central pain in the spine which is relieved by lying down.
• Major trauma
• Minor trauma in people with osteoporosis.
• Structural deformity of the spine
• Point tenderness over the vertebral body.

Question 10

What are the red flag sx for cancer/infection of spine?

Answer 10

• Pain that remains when lying down
• pain that disturbs sleep
• Onset in people aged above 50 years or below 20 years.
• History of cancer.
• Constitutional symptoms, such as fever, chills, or unexplained weight loss.
• Recent bacterial infection - eg, urinary tract infection.
• Intravenous drug misuse.
• Immune suppression.
• Structural deformity of the spine (such as scoliosis).
• Point tenderness over the vertebral body.

Question 11

What are the differential diagnosis for back pain?

Answer 11

• Primary malignancy
  
  • myeloma
• Secondary cancers
  
  • lung, breast, prostate, kidney, thyroid
• Bone disorder
  
  • Paget’s disease
  • Osteoporosis
  • Spinal stenosis
• Inflammatory disease
  
  • Ankylosing spondylitis
• Infection
  
  • TB/ osteomyelitis
• Non spinal related
  
  • Dissecting aortic aneurysm

Question 12

What Ix would you order for LBP?

Answer 12

• If simple LBP - no need Ix
• Imaging
  
  • Xray of lumbar spine -
    
    • only if fracture or mets suspected
    • not routinely used as very high radiation exposure
  • CT
    
    • for stress fractures
    • for spondylolisthesis
  • MRI
    
    • for disc lesion, nerve root compression, discitis

Question 13

What other ix would you order for LBP?

Answer 13

• FBC, ESR, CRP, urine analysis if cancer, infection or inflammation is suspected
• LFTs - Alkaline phosphatase can be elevated in metastatic disease and Paget’s disease of bone.
• PSA - raised in carcinoma of the prostate.
• Urinary hydroxyproline- raised in Paget’s disease of bone.

Question 14

How would you mx simple LBP?

Answer 14

• Conservative
  
  • reassurance and advice
  • advise to stay active
  • reduce RF
• Pharmacological
  
  • First line
  • NSAIDs - low dose, short course
  • Muscle relaxant
  • Second line
  • weak opioids

Question 15

What does yellow flags mean in LBP?

Answer 15

• psychosocial barriers to active rehabilitation

Question 16

What are the examples of yellow flags in LBP?

Answer 16

• Belief that pain and activity are harmful.
• Sickness behaviors, such as extended rest.
• Social withdrawal.
• Emotional problems such as low or negative mood, depression, anxiety and stress.
• Problems with claims or compensation, or time off work.

Question 17

What are the mx for lumbar disc herniation?

Answer 17

• Conservative
  
  • analgesia
  • NSAID
  • manual therapy
  • Epidural corticosteroid injections
• Surgery
  
  • Lumbar discectomy - if severe nerve compression or when unresponsive to conservative treatment

Question 18

When would you refer a pt with LBP to secondary care?

Answer 18

• If red flags suggest a serious condition
• If there is progressive, persistent or severe neurological deficit
• If pain or disability remain problematic for more than a week or two
• If, after six weeks, sciatica is still disabling and distressing
  *

Question 19

Generally, what is the prognosis of simple LBP?

Answer 19

• majority improve within 6 weeks