Patient Presentation of Back Pain Flashcards
Different presentations of back pain?
Pain:
• Localised
• Lumbar
Referred pain:
• E.g: sciatica
Stiffness
Loss of sleep
Loss of function:
• Walking
• Lifting
• Carrying (hence often affects the ability to work)
What to clarify in the history?
Pain (type and any radiation) - tends to be at L4/5; if higher, would be more suspicious
Loss of function (subjective)
Trauma (recent/past)
Previous surgery
Symptoms suggestive of other pathology: • Urinary tract • GI • Respiratory • Systemic illness
Physical examination of a patient with back pain?
Inspection:
• Patient walking in/out
• Deformity, e.g: scoliosis, kyphosis, scars (previous operations
Palpation:
• Spinal tenderness
• Paravertebral muscles
Movement:
• Flexion, extension, lateral flexion
• Straight leg raise
• Tone, power, reflexes, sensation in legs (if indicated)
Ix for back pain?
Normally, none are required
ESR/PV/Ca/Alk phos (may increase if there is bone damage, e.g: from a metastases)
X-ray (rarely) - 50% of lumbar spine; x-rays in people without back pain always show some degree of degeneration)
MRI
Flow chart for adult lower back pain?
ADD FLOW CHART IMAGE
When is an MRI indicated?
If there are red flags
OR
If considering surgery (non-resolving sciatica, spinal stenosis)
Causes of back pain?
Mechanical/non-specific (majority)
Tumour/metastases
Ankylosing spondylitis (inflammatory)
Infection, e.g: TB
Red flag signs with back pain?
Age <20, e.g: scoliosis, or >50
Thoracic pain (abnormal)
Previous carcinoma (breast, bronchus, prostate, thyroid, kidney)
Immunocompromised (steroids can cause osteoporosis, HIV)
Feeling unwell
Weight loss
Widespread neurological symptoms, i,e: more than just sciatica
Structural spinal deformity
Yellow flags (indicate that the pain is more psychological) for chronic back pain?
- Low mood
- High levels of pain/disability
- Belief that activity is harmful
- Low educational level
- Obesity
- Problem with claim/compensation (secondary gain)
- Job dissatisfaction
- Light duties not available at work
- Alot of lifting at work
Management of back pain?
- Explanation and reassurance
- Encouragement to MOBILISE
- Cultivate positivity
- Analgesics, e.g: paracetamol, co-analgesics, opiates (pain ladder); can use NSAIDs short-term
- Muscle relaxants short-term, e.g: diazepam, for people with excessive muscle spasm
- Physiotherapy, osteopathy, chiropractic
- Referral
How does femoral nerve irritation present?
Anterior thigh pain
Cautions with back pain?
Ask about urinary/bowel symptoms (checking for cauda equina syndrome)
Do a PR exam (anal tone, peri-anal sensation, etc)
Why is back pain an example of a heart sink symptom?
There is not always a definitive reason for the back pain
Neurological symptoms of back pain?
Include numbness, paraesthesia, weakness or may be more subtle subtle, such as temperature disturbance
Conservative management of backache?
- Short bed rest (discredited and only for patients who have no other option)
- Anti-inflammatory +/-
- Muscle relaxant
- Mobilise
- Place of physical therapies, X-ray, etc
- Return to normal activity
Second line treatment of
- Education/instruction/ reassurance
- Physiotherapy
- Osteopathy/chiropractic
- TENS/psychology/pain clinic
- Complementary therapies
- Surgery
When is a prolapsed disc an emergency?
Only a surgical emergency if there are cauda equina symptoms/signs
However, long-term results for prolapsed disc surgery are the same whether or not
Presentation of spinal claudication?
Tends to be in an older age group and more common in males
Tends to be manual workers but obesity is now a major factor; there is limited walking capacity and people often have to stoop/sit/lean forward to relieve symptoms
“Heavy/tired” legs
Differences between spinal and vascular claudication?
Spinal is:
Relieved by flexing
Uphill is often bad
Cycling easy
Vascular is:
Relieved by standing
Uphill is bad
Cycling bad
Typical X-ray appearance of spinal stenosis or spinal claudication?
Degenerate, hypertrophic spine with narrow interpedicular distance and obliteration of the neural foramena
Characteristics of discogenic pain?
Worse as the day goes on, worse on flexion and with activity
Deep-seated central lower low back pain
Segmental instability (greater than normal range of motion/“hypermobility” between two vertebral segments) - typically a background ache with exacerbations/remissions (often for no apparent reason)
Presentation of facet arthropathy?
Stiff in the morning and patient have a “loosen up routine”
Difficulty sitting, driving, standing
Worse with extension and better with activity
Often radiates to buttocks and legs
