MSK: Back Pain & Sciatica Flashcards
What is another name for lower back pain?
Lumbago
What is non-specific or mechanical lower back pain?
Refers to the majority of patients who do not have a specific disease causing their lower back pain.
What is sciatica?
refers to the symptoms associated with irritation of the sciatic nerve.
Typical length of sciatica recovery?
4-6 weeks
Chronic lower back pain can have a massive impact on the patient’s quality of life and be difficult to manage.
What are some challenges with managing patients with lower back pain?
1) Identifying serious underlying pathology
2) Speeding up recovery
3) Reducing the risk of chronic lower back pain
4) Managing symptoms in chronic lower back pain
Causes of mechanical back pain?
1) Muscle or ligament sprain
2) Facet joint dysfunction
3) Sacroiliac joint dysfunction
4) Herniated disc
5) Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
6) Scoliosis (curved spine)
7) Degenerative changes (arthritis) affecting the discs and facet joints
Give some causes of neck pain
1) Muscle or ligament strain (e.g., poor posture or repetitive activities)
2) Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
3) Whiplash (typically after a road traffic accident)
4) Cervical spondylosis (degenerative changes to the vertebrae)
What are some RED FLAG features of lower back pain?
1) Age <20 or >50 y/o
2) history of previous malignancy
3) night pain
4) history of trauma
5) systemically unwell e.g. weight loss, fever
What are some RED FLAG causes of lower back pain?
1) Spinal fracture
2) Cauda equina
3) Spinal stenosis
4) Ankylosing spondylitis
5) Spinal infection
What may make you think ‘spinal fracture’ in back pain?
Major trauma
What may make you think ‘cauda equina’ in back pain?
- Saddle anaesthesia
- Uinary retention
- Incontinence
- Bilateral neurological signs
What may make you think ‘spinal stenosis’ in back pain?
Intermittent neurogenic claudication
What may make you think ‘ankylosing spondylitis’ in back pain?
- Age under 40
- gradual onset
- morning stiffness
- night-time pain
What may make you think ‘spinal infection’ in back pain?
- fever
- history of IV drug use
Keep in mind that back pain may not always be related to the spine.
Give some abdominal or thoracic conditions that can cause back pain
Pneumonia
Ruptured aortic aneurysms
Kidney stones
Pyelonephritis
Pancreatitis
Prostatitis
Pelvic inflammatory disease
Endometriosis
Describe the onest of spinal stenosis
Gradual
Describe the pain in spinal stenosis
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking.
Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
What can relieve pain in spinal stenosis?
sitting down, leaning forwards and crouching down
What is required to diagnose spinal stenosis?
MRI
Who is ankylosing spondylitis typically seen in?
Typically a young man who presents with lower back pain and stiffness
When is pain in ankylosing spondylitis worse? What improves it?
Stiffness is usually worse in morning and improves with activity
What spinal nerves form the sciatic nerve?
L4-S3
Where does the sciatic nerve exit the posterior part of the pelvis?
Through the greater sciatic foramen, in the buttock area on either side and travels down the back of the leg.
At the knee, what does the sciatic nerve divide into?
tibial nerve and common peroneal nerve
Where does the sciatic nerve supply SENSATION to?
lateral lower leg and the foot
Where does the sciatic nerve supply MOTOR function to?
posterior thigh, lower leg and foot
Describe the pain in sciatica
UNILATERAL pain from the buttock radiating down the back of the thigh to below the knee or feet.
It might be described as an “electric” or “shooting” pain.
Symptoms of sciatica?
- Unilateral pain radiating down back of thigh
- paraesthesia (pins and needs)
- numbness
- motor weakness
- reflexes may be affected on that side
What are the 3 main causes of sciatica
Lumbosacral nerve root compression by:
1) herniated disc
2) Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
3) spinal stenosis
What is spondylolisthesis?
anterior displacement of a vertebra out of line with the one below
What is BILATERAL sciatica a red flag for?
Cauda equina syndrome
Key symptoms/things to ask in back pain history:
Major trauma (spinal fracture)
Stiffness in the morning or with rest (ankylosing spondylitis)
Age under 40 (ankylosing spondylitis)
Gradual onset of progressive pain (ankylosing spondylitis or cancer)
Night pain (ankylosing spondylitis or cancer)
Age over 50 (cancer)
Weight loss (cancer)
Bilateral neurological motor or sensory symptoms (cauda equina)
Saddle anaesthesia (cauda equina)
Urinary retention or incontinence (cauda equina)
Faecal incontinence (cauda equina)
History of cancer with potential metastasis (cauda equina or spinal metastases)
Fever (spinal infection)
IV drug use (spinal infection)
In a back pain history, what would IV drug use indicate?
Spinal infection
In a back pain history, what would stiffness in morning or with rest indicate?
ankylosing spondylitis
In a back pain history, what would age <40 indicate?
ankylosing spondylitis
In a back pain history, what would gradual onset indicate?
ankylosing spondylitis or cancer
In a back pain history, what would night pain indicate?
ankylosing spondylitis or cancer
In a back pain history, what would bilateral neurological motor or sensory symptoms indicate?
cauda equina
In a back pain history, what would saddle anaesthesia indicate?
cauda equina
In a back pain history, what would urinary retention or incontinence indicate?
cauda equina
In a back pain history, what would faecal incontinence indicate?
cauda equina
In a back pain history, what would a history of cancer indicate?
potential metastasis (cauda equina or spinal metastases)
In a back pain history, what would a fever indicate?
spinal infection
In cauda equina, what examination findings may there be?
1) Bilateral neurological motor or sensory signs
2) Bladder distention implying urinary retention
3) Reduced anal tone on PR examination
What test can be used to help diagnose sciatica?
Sciatic stretch test
Describe the sciatica stretch test
1) The patient lies on their back with their leg straight.
2) The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees).
3) Then the examiner dorsiflexes the patient’s ankle.
Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. Symptoms improve with flexing the knee.
What are the 5 main cancers that metastasise to bone
1) prostate
2) renal
3) thyroid
4) breast
5) lung
What imaging can be used to diagnose spinal fractures?
xrays or CT scans
What imaging is needed in suspected cauda equina?
Emergency MRI scan
3 investigations for ankylosing spondylitis?
1) Inflammatory markers (CRP and ESR)
2) X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease)
3) MRI of the spine (may show bone marrow oedema early in the disease)
What is the STarT back tool?
Used to stratify the risk of a patient presenting with acute back pain developing chronic back pain.
What is cauda equina syndrome?
a rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed
Who should you consider cauda equina in?
Any patient presenting with new/worsening lower back pain
What can late diagnosis of cauda equina result in?
permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence.
What is the most common cause of cauda equina?
Central disc prolapse (typically at L4/5 or L5/S1)
Causes of cauda equina:
- central disc prolapse
- tumours: primary or metastatic
- infection: abscess, discitis
- trauma
- haematoma
Possible features of cauda equina?
- Back pain
- Bilateral sciatica (about 50% of cases)
- Reduced sensation/pins-and-needles in the perianal area
- Decreased anal tone (always check)
- Urinary dysfunction e.g. incontinence, reduced awareness of bladder filling, loss of urge to void
Investigation in cauda equina?
Urgent MRI
Management of cauda equina?
surgical decompression
1st line pharmacological management of back pain?
NSAIDs
Investigations in potential ankylosing spondylitis?
Inflammatory markers and an urgent rheumatology review
What tool can be used to stratify the risk of developing chronic back pain?
StarT Back tool
Management of patients at low risk of chronic back pain?
Self-management
Education
Reassurance
Analgesia
Staying active and continuing to mobilise as tolerated
Additional management options for patients at medium or high risk of developing chronic back pain?
Physiotherapy
Group exercise
Cognitive behavioural therapy
Pharmacological management options in chronic back pain?
1st line –> NSAIDs (e.g., ibuprofen or naproxen)
Alternative –> Codeine
Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
What should you NOT prescribe for chronric back pain
opioids, antidepressants, amitriptyline, gabapentin or pregabalin
Safetynetting patients with back pain?
Seek urgent medical attention if:
- Saddle anaethesia
- Incontinence (urinary or faecal)
What is saddle anaesthesia?
Saddle anaesthesia refers to reduced sensation in the area that would be in contact with a saddle if sitting on one. This includes the perineum, buttocks, anus, groin and upper thighs.
What can be a management option for patients with chronic low back pain originating in the facet joints?
Radiofrequency denervation –> used to target and damage the medial branch nerves that supply sensation to the facet joints associated with the back pain.
If sciatica symptoms are persisting or worsening at follow up, what can be offered?
a neuropathic medication:
1) amitripyline
2) duloxetine
What is chronic fatigue syndrome?
When is it diagnosed?
Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time, in the ABSENCE of other disease which may explain symptoms.
Is past psychiatric history a risk factor in chronic fatigue syndrome?
No
Symptoms of chronic fatigue syndrome?
1) Fatigue (central feature)
2) Sleep problems e.g. insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle
3) muscle and/or joint pains
4) headaches
5) painful lymph nodes without enlargement
6) sore throat
7) cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding
8) physical or mental exertion makes symptoms worse
9) general malaise or ‘flu-like’ symptoms
10) dizziness
11) nausea
12) palpitations
Investigations in chronic fatigue syndrome?
Carry out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis
How long must symptoms be present for in chronic fatigue syndrome to make a diagnosis?
3 months
Management options in chronic fatigue syndrome?
1) refer to a specialist CFS service
2) energy management
3) physical activity and exercise –> BUT do not advise people with ME/CFS to undertake exercise that is not part of a programme overseen by an ME/CFS specialist team
4) cognitive behavioural therapy
Does chronic fatigue syndrome have a better prognosis in adults or children?
Children
