ʟower back pain

Question 1

What are the 4 screening questions for lower back painʔ

Answer 1

1) onset (sudden or related to trauma)
2) Motor or sensory symptoms or bothʔ (ɪs it loss of function, any saddle numbnessʔ)
3) ɪs the bladder or bowel affectedʔ
4) ɪs there sciaticaʔ (pain through buttock, back of thigh, below knee and into calf and ankle - caused by sciatic nerve irritation by prolapsed disc)

Question 2

What are the 2 main ways in which a prolapsed disc occursʔ

Answer 2

1) Disc rupture following strenuous exercise or sudden exertion in young adults.
2) Disc herniation following minimal stress, due to degenerative disc disease and spondylosis in older patients.
* disc herniates laterally causing nerve root compression*

Question 3

What are the most common levels at which disc prolapse most commonly occursʔ

Answer 3

• C5/C6 (pain can radiate to shoulder and arm)

- ʟ5/S1 (causes sciatica, pain down buttock to back of leg)

Question 4

What are some causes of back painʔ

Answer 4

1) prolapsed intervertebral disc
2) Osteoarthritis
3) Ankylosing spondylitis
4) bone metastases
5) myeloma
6) vertebral collapse due to osteoporosis

Question 5

What is ankylosing spondylitisʔ

Answer 5

inflammation of spine causing stiffness and vertebrae to fuse.

• usually at sacro iliac joints
• onset in late teens / 20’s

Question 6

What is the difference in symptoms between a lumbar disc prolapse and spinal stenosisʔ

Answer 6

ʟumbar disc prolapseː

• paraesthesiae (pins and needles) + numbness
• usually in OɴE leg

Spinal stenosisː

• paraesthesiae and numbness
• BɪʟATEʀAʟ
• urinary / bowel incontinence (late presentation)
• leg claudication
• spinal stenosis can cause spinal cord compression so is a medical emergency if rapid onset.

Question 7

A prolapsed disc can cause cauda equina syndrome (medical emergency) - what are the red flags for thisʔ

Answer 7

Red flags that suggest cauda equina syndrome include:
1) Severe or progressive BɪʟATEʀAʟ neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.

2) Recent-onset UʀɪɴAʀʏ ʀETEɴTɪOɴ (caused by bladder distension because the sensation of fullness is lost)

and/Oʀ

UʀɪɴAʀʏ ɪɴCOɴTɪɴEɴCE (caused by loss of sensation when passing urine).

Recent-onset FAECAʟ ɪɴCOɴTɪɴEɴCE (due to loss of sensation of rectal fullness).

3) SADDʟE SEɴSOʀʏ ʟOSS (anaesthesia or paraesthesia).
4) Unexpected ʟAXɪTʏ OF AɴAʟ SPɪɴCTEʀ.

Question 8

What investigations can be done for disc prolapseʔ

Answer 8

1) Mʀɪ (very sensitive to disc prolapse)
2) CT (if red flags)
3) Bone scan (to rule out malignancy)
4) Bloods (FBC, U+Es, ESʀ/CʀP - for red flags)
5) Xray can show bone disformities

Question 9

What is the management and treatment for disc prolapseʔ

Answer 9

*Symptoms usually subside within 6 months.

1) Analgesia (ɴSAɪDs, paracetamol, codeine)
2) physiotherapy
3) stay active

Question 10

What is nocturnal back pain a sign ofʔ

Answer 10

tumour