non-specific back pain

Question 1

common causes

Answer 1

facet joint problems
intervertebral disc herniation
sciatica
muscle strain
ligamentous strain
spondylosis (degenerative OA)

Question 2

serious causes not to miss

Answer 2

cauda equina syndrome
osteoporotic compression fracture
ruptured AAA
retroperitoneal hemorrhage (anticoagulants)
neoplastic eg. myeloma, bone metastases
infections
- osteomyelitis
- epidural abcess
- septic discitis
- tuberculosis
- pelvic abscess/PID

Question 3

less serious causes of non specific back pain

Answer 3

MSK/neurological
- facet joint dysfunction
- intervertebral disc prolapse
- sciatica
- muscle strain
- ligamentous strain
- spondylosis (degenerative OA)
- sacroiliac dysfunction
- spondylolisthesis
- spinal canal stenosis
- paget disease
rheumatological
- ankylosing spondylitis
- reactive arthritis
- psoriasis
IBD
vascular claudication
prostatitis
endometriosis
UTI

Question 4

type of pain of nerve root compression

Answer 4

intense, sharp, stabbing

Question 5

type of pain of sciatica

Answer 5

sharp shooting pain down the back of the leg

Question 6

inflammatory type pain

Answer 6

insidious onset, aching, morning stiffness, worse with rest, relieved by activity

Question 7

screening tests in chronic back pain

Answer 7

plain x-ray
urine dipstick
FBC, ESR/CRP
serum alkaline phosphatase
other specific tests based on symptoms and age

Question 8

conservative management of mechanical back pain

Answer 8

advise to stay active, discourage bed rest
paracetamol, NSAIDs, muscle relaxants
consider physiotherapy referral for exercise, spinal manipulation, pilates
patient education: ceasing activity only weakens muscles and worsens pain

Question 9

red flags

Answer 9

age onset <20 or >55
non-mechanical pain (unrelated to activity)
pain at night/rest
thoracic pain (aortic dissection/ruptured AAA)
weight loss
nightsweats
Hx of cancer, steroids or HIV
fatigue, feeling unwell
structural spinal deformity

Question 10

specific red flags for cauda equina syndrome

Answer 10

saddle anaesthesia, urinary retention/incontinence, bowel changes, paresthesia in legs, weakness in legs, sciatica type pain (or absense of pain), loww of anal tone on DRE, gait disturbance, sexual dysfunction

Question 11

psychosocial factors that increase risk of pain becoming chronic

Answer 11

low education
somatisation
fear avoidance
depression
lack of social support
treatment refusal
outstanding worker’s compensation claim
unsociable working hours
obesity

Question 12

define cauda equina syndrome

Answer 12

damage to or compression of the cauda equina (nerve fibers L3-S5) located below L2
common causes include trauma, tumours, large posteromedial disc herniation

Question 13

define conus medullaris syndrome

Answer 13

damage to or compression of the spinal word at the vertebral level T12-L2
common causes include spondylolisthesis, tumours and trauma

Question 14

sensory symtpoms of cauda equina

Answer 14

saddle aneaesthesia
- lack of sensitivity in the dermatomes S3-S5, affecting the areas around the anus, genitalia, and inner thighs (may be asymmetic)
asymmetric numbness in lower limb dermatomes

Question 15

urogenital and rectal symtoms of cauda equina

Answer 15

late onset of urinary reteention
change in bowel habits due to loss of anal sphincter control
decreased rectal tone or bulbocavernosus reflex
erectile dysfunction

Question 16

urogenital and rectal symptoms of conus medullaris syndrome

Answer 16

early onset of bladder and faecal incontinence
erectile dysfunction

Question 17

what type of motor neuron signs would you expect in cauda equina/conus medullaris

Answer 17

cauda equina syndrome typically manifests with LMN signs whereas conus medullaris and spinal cord compression usually manifest with a combination of LMN signs and UMN signs

Question 18

management of compressive spinal emergencies

Answer 18

urgent MRI without contrast
consult neurosurgery for urgent surgical decompensation
administer analgesics
treat the underlying cause