Lower back pain + prolapsed discs

Question 1

Red flags for lower back pain

Answer 1

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

Question 2

Gradual onset
Unilateral or bilateral leg pain (+/- back pain), numbness, and weakness which is worse on walking.
Resolves when sits down.
Pain described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

Answer 2

Spinal stenosis

Question 3

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)

Answer 3

Ankylosing spondylitis

Question 4

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

Answer 4

Peripheral vascular disease

Question 5

Describe the distribution of pain in a prolapsed disc

Answer 5

clear dermatomal leg pain associated with neurological deficits

Question 6

Features of lumbar spine pain due to prolapsed disc

Answer 6

leg pain usually worse than back
pain often worse when sitting

Question 7

Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test

Answer 7

L3 nerve root compression

Question 8

Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test

Answer 8

L4 nerve root compression

Question 9

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

Answer 9

L5 nerve root compression

Question 10

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

Answer 10

S1 nerve root compression

Question 11

Management

Answer 11

analgesia (NSAIDs + PPI first line_
physiotherapy
exercises
if symptoms persist e.g. after 4-6 weeks then referral for consideration of MRI is appropriate