Pain

Question 1

Red flags of sinister cause of back pain

Answer 1

Aged <20 yrs or >55 years old
Acute onset in elderly
Constant/progrrssive pai
Nocturnal pain
Worse pain on being supine
Fever, night sweats, weight loss
History of malignancy
Abdominal mass
Thoracic back pain
Morning stiffness
Bilateral/alternating leg pain
Neurological disturbance (including sciatica)
Sphincter disturbance
Infection - current or reccurent
Immunosupression e.g. HIV, Steroids
Leg claudication or exercise-related leg weakness/numbness (spinal stenosis)

Question 2

Investigations of back pain

Answer 2

If suspect specific cause, test it
Red flag symptoms: FBC, ESR and CRP (myeloma, infection, tumour), U&E, ALP, serum/urine electrophoresis
MRI = imaging of choice
X-ray can exclude bony abnormalities and fractures

Question 3

Management of back pain

Answer 3

Keep diagnosis under review
Non-specific back pain: patient education and self-management
Continue normal activities and be active

Paracetamol +/- NSAIDs +/- Codeine
Low dose amitriptyline if these fail

Physiotherapy or exercise programme if not improving

Question 4

Nerve root lesion for pain in upper thigh

Answer 4

L2

Question 5

Nerve root lesion for pain in lower thigh

Answer 5

L3

Question 6

Nerve root lesion for pain in knee to medial malleolus

Answer 6

L4

Question 7

Nerve root lesion for pain in Lateral shin of foot and great toe

Answer 7

L5

Question 8

Nerve root lesion for pain in posterior calf to lateral foot and little toe

Answer 8

S1

Question 9

Reflex affected if nerve root lesion at:
L2
L3
L4
L5
S1

Answer 9

L2 - nil
L3 - knee jerk
L4 - knee jerk
L5 - great toe jerk
S1 - ankle jerk

Question 10

CNS causes of facial pain

Answer 10

Migraine
Trigeminal neuralgia
Glossopharyngeal neuralgia

Question 11

Vascular and non-neurological causes of facial pain

Answer 11

Neck - cervical disc pathology
Bone/sinuses - sinusitis; neoplasia
Eye - glaucoma; iritis; orbital cellulitis; eye strain; AVM
Temporomadibular joint - arthritis or idiopathic dysfunction (common)
Teeth/gums - caries; broken teeth; abscess; malocclusion
Ear - Otitis media; Otitis externa
Vascular/vasculitis - arteriovenous fistula; aneurysm; giant cell arteritis; SLE