MECHANICAL LOWER BACK PAIN Flashcards
What is mechanical lower back pain?
- Lumbar back pain is a common symptom experienced by most people at some point in their lives
- Only a few patients have a serious underlying pathology.
What are that could be responsible for lower back pain?
- Cauda equina syndrome – requires emergency admission
- Spinal fracture – requires immediate assessment for stability
- Cancer.
- Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess).
What are some red flags to look out for that could suggest these serious underlying conditions?
- bilateral leg neurology (cauda equina)
- incontinence(cauda equina)
- saddle anaesthesia(cauda equina)
- sudden onset pain(spinal fracture)
- high impact trauma(spinal fracture)
- unexplained weight loss
- history of cancer
- severe pain that remains on lying down, wakes from sleep(cancer)
- fever
- TB/HIV
- structural deformity
- IVDU
What is simple back pain?
back pain with no nerve root irritation or serious spinal injury does not require specialist referral
What is simple back pain characterised by?
- Onset between 20 - 55 years
- Presence of lumbosacral, buttock and thigh pain
- Pain which is ‘mechanical’ in nature, varying with physical activity and with time.
- The patient is otherwise well with no systemic features.
- The clinical features typically resolve within six weeks.
- Pain may persist or relapse over time
What is the treatment of simple back pain?
- Conservative management in the community with analgesia
- don’t need scan at this point, but make sure they know the red flags and to go to hospital immediately if any of these present.
- Should recover in 6 weeks.
Describe the pathophysiology of lumbar disc prolapse
- tends to affect younger people (20-40) because the discs degenerate with age making a prolapse unlikely
- When an intervertebral disc prolapses the central nucleus pulposus is forced or extruded posterolaterally causing the annulus fibrosis to bulge
- complete prolapse occurs when the nucleus pulposus extends beyond the annulus fibrosis.
- clinical produced when extrusion impinges on the spinal nerve roots and spinal cord.
What is the correlation between size of prolapse and symptoms?
- no correlation
- severity and pattern of the symptoms and signs depend on the site of the prolapsed intervertebral disc
What are clinical features of a lumbar disc prolapse?
- Sudden or insidious onset of severe low back pain
- Muscle spasm
- Localised tenderness
- Diminished lumbar spinal movements and a visible scoliosis.
- Typically occurs during an episode of coughing, lifting, sneezing or twisting in which there is a recent history of trauma, back strain or injury.
- If there nerve root involvement, severe unilateral shooting pains radiate to buttocks, thigh or calf as well as paraesthesia, numbness and other neurological signs, depending on the particular nerve root involved.
What are investigations for lumbar disc prolapse?
MRI
What is the treatment for lumbar disc prolapse?
- Conservative - Bed rest
- Pharmacological - Analgesia, corticosteroid injection
- Surgical - Only considered for severe or increasing neurological impairment e.g. bladder symptoms.
- Physiotherapy is used post op to aid in recovery
What can vertebral crush fractures lead to?
- can be asymptomatic
- only 1/3 are associated with sudden onset of localised severe back pain which can continue for 6 months or more
- there can be also increased height loss, kyphosis, decreased activity and an impaired quality of life.
What is the treatment for vertebral crush fractures?
- Non-pharmacological - bed rest and analgesia followed by gradual mobilisation.
- Further investigations for the aetiology of the insufficiency fracture are then undertaken and if indicated anti-osteoporosis treatments are instituted.
What is spondylolisthesis?
What can cause spondylolisthesis?
can be congenital or acquired and is due to a defect in the pars interarticularis
