(msk) back pain Flashcards
what are the types of back pain?
non-specific lower back pain
mechanical lower back pain
nerve root pain (sciatica)
define non-specific lower back pain
pain not due to any specific or underlying disease that can be found
(could have pathological causes that are yet to be diagnosed)
define mechanical lower back pain
pain after abnormal stress and strain on the vertebral column
(pain associated w joint & limbs)
define nerve root pain
pain radiating to the lower limbs with or without neuralgic symptoms
what are the non-mechanical causes of lower back pain?
tumour including myeloma
infection
spondyloarthropathy
pars interarticularis injury
compression fracture
visceral (referred from abdomen e.g. dissecting aortic aneurysm, pancreatitis)
what are the mechanical causes of lower back pain?
disc degeneration
disc herniation
annular tears
facet joint osteoarthritis
instability
what are some possible visceral causes of lower back pain?
referred from abdomen e.g. dissecting aortic aneurysm, pancreatitis
why is imaging not routinely offered for lower back pain in a non-specialist setting?
1) lower back pain is an extremely common presentation
2) likely to improve on conservative management within the first 6 weeks so imaging not usually indicated (unless red flag symptoms)
when is imaging usually offered for lower back pain?
in a specialist setting when conservative management has not improved the condition of the patient
why can imaging sometimes not be offered for lower back pain even in a specialist clinical setting?
the specialist may be able to work out the cause without needing imaging
when is imaging specifically indicated for lower back pain?
in a specialist setting when
1) conservative management has not worked to improve the patient’s condition
2) if imaging is likely to change the management of the patient
what conservative treatments are available for lower back pain?
analgesia (Paracetamol)
anti-inflammatory drugs
manipulation
acupuncture
massage
!! allow some time to pass !!
is bed rest recommended for patients with lower back pain?
no!
= does not result in a faster recovery; instead, try to keep the patient mobile
which are the most preferred treatments for lower back pain?
exercise (best one)
manipulation, psychological therapy
NSAIDs, weak opioids
radiofrequency denervation
epidural
which are the less preferred but reasonable treatments for lower back pain?
acupuncture
corsets, traction
paracetamol, opioids
ultrasound, TCNS (transcutaneous nerve stimulation)
injections
spinal fusion, disc replacement
what are some indicators of sciatica in the patient history?
unilateral leg pain greater than low back pain
pain radiating to the foot or toes
numbness or paraesthesia in the same regions
what are some indicators of sciatica in the clinical examination?
straight leg raising test induces more leg pain
localised neurology (limited to one nerve root)
what are the red flag symptoms of lower back pain?
weight loss
fever
night pain
under 19 years
what are the red flag symptoms of leg pain?
bowel/bladder dysfunction
saddle anaesthesia
profound neurological deficit (i.e. cannot move legs)
why must lower back pain that appears pathological be diagnosed as quickly as possible?
delays in diagnosis cause paralysis and fractures
why are spinal metastases dangerous?
can risk compression of the vertebral column an spinal cord that can lead to catastrophic fractures and paralysis respectively
how do spinal metastases appear on a spinal MRI?
multiple deposits of different sizes in different parts
which cancers most commonly metastasise to the spine?
breast, prostate, lung, bowel
why must individuals under 35 years of age who experience back pain for more than 3 months have a spinal MRI?
may have inflammatory arthropathy
+
early diagnosis allows more effective treatment with biologics (prevents lifelong morbidity)
does early detection help in treating spinal metastases?
not usually
= early diagnosis does not usually help with prognosis
does early detection help in treating inflammatory arthropathy?
yes
= early treatment with biologics is said to be very effective and prevents lifelong morbidity
does early detection help in treating spinal myeloma?
yes
= early diagnosis catches the disease at a more easily treatable stage
why is tuberculosis of the spine dangerous?
1) subtle symptoms can be missed and this allows progression of disease
2) advanced disease can cause compress the spinal cord and cause paralysis
does early detection help in treating tuberculosis of the spine?
yes
= early diagnosis is essential for effective treatment
what is the primary method of imaging for lower back pain?
spinal MRI scan
less preferred = radiograph, CT scan
why are radiographs not commonly used for imaging for lower back pain?
1) overlook most important diseases (e.g. metastases, myeloma)
2) radiation exposure
how can Paget’s sarcoma cause lower back pain?
abdominal soft tissue can erode into vertebrae and cause compression of the spinal cord
how can anorexia nervosa cause lower back pain?
aneroxia nervosa
= impaired nourishment
= osteoporosis
so there is an increased risk of vertebral compression fractures
a 12-year-old presents with lower back pain
what should you do to investigate, and why?
do a spinal MRI
= can be due to adolescent disc prolapse (rare, but not impossible!)
in which scenario do some MRI scans not pick up lesions?
in T2-weighted MRI scans
bony mets usually picked up on T1-weighted MRI scans
what is an osteoid osteoma?
a benign bone tumour
what are some specialist treatments for lower back pain?
(analgesia)
facet injections (local & steroid, denervation)
nerve root block
epidural injection
surgery/neurostimulation
what are facet injections for lower back pain and why are they done?
injection of local anesthetic (numbing medicine) into a facet joint
1) to help diagnose the facet joints as the source of the patient’s pain
2) to provide pain relief
how are facet injections administered for lower back pain?
using a 21g needle into the facet joint
one level at a time
inside/around the joint
what do local facet injections contain?
marcain 0.5%, 1ml
what do steroid facet injections contain?
trimcinolone, 20mg
what is nerve root block for lower back pain?
injection of medication around the structure to block pain from specific nerves
what are the types of nerve root block available?
CT-guided root block
MRI-US fusion root block (using VNav needle guidance)
what are the three types of epidural steroid injections?
caudal
transforaminal
interlaminar
which surgical options are available for lower back pain?
decompression of nerve roots
decompression of spinal stenosis
disc replacement
spinal fusion surgery
at which week is imaging usually done for lower back pain?
red flag symptoms = done immediately
no red flag symptoms, but no improvement after 6 weeks of conservative management = imaging
