Patient Presentation of Back Pain

Question 1

Different presentations of back pain?

Answer 1

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)

Question 2

What to clarify in the history?

Answer 2

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

Question 3

Physical examination of a patient with back pain?

Answer 3

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)

Question 4

Ix for back pain?

Answer 4

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

Question 5

Flow chart for adult lower back pain?

Answer 5

ADD FLOW CHART IMAGE

Question 6

When is an MRI indicated?

Answer 6

If there are red flags

OR

If considering surgery (non-resolving sciatica, spinal stenosis)

Question 7

Causes of back pain?

Answer 7

Mechanical/non-specific (majority)

Tumour/metastases

Ankylosing spondylitis (inflammatory)

Infection, e.g: TB

Question 8

Red flag signs with back pain?

Answer 8

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

Question 9

Yellow flags (indicate that the pain is more psychological) for chronic back pain?

Answer 9

• 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

Question 10

Management of back pain?

Answer 10

1. Explanation and reassurance
2. Encouragement to MOBILISE
3. Cultivate positivity
4. Analgesics, e.g: paracetamol, co-analgesics, opiates (pain ladder); can use NSAIDs short-term
5. Muscle relaxants short-term, e.g: diazepam, for people with excessive muscle spasm
6. Physiotherapy, osteopathy, chiropractic
7. Referral

Question 11

How does femoral nerve irritation present?

Answer 11

Anterior thigh pain

Question 12

Cautions with back pain?

Answer 12

Ask about urinary/bowel symptoms (checking for cauda equina syndrome)

Do a PR exam (anal tone, peri-anal sensation, etc)

Question 13

Why is back pain an example of a heart sink symptom?

Answer 13

There is not always a definitive reason for the back pain

Question 14

Neurological symptoms of back pain?

Answer 14

Include numbness, paraesthesia, weakness or may be more subtle subtle, such as temperature disturbance

Question 15

Conservative management of backache?

Answer 15

• 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

Question 16

Second line treatment of

Answer 16

• Education/instruction/ reassurance
• Physiotherapy
• Osteopathy/chiropractic
• TENS/psychology/pain clinic
• Complementary therapies
• Surgery

Question 17

When is a prolapsed disc an emergency?

Answer 17

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

Question 18

Presentation of spinal claudication?

Answer 18

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

Question 19

Differences between spinal and vascular claudication?

Answer 19

Spinal is:
Relieved by flexing
Uphill is often bad
Cycling easy

Vascular is:
Relieved by standing
Uphill is bad
Cycling bad

Question 20

Typical X-ray appearance of spinal stenosis or spinal claudication?

Answer 20

Degenerate, hypertrophic spine with narrow interpedicular distance and obliteration of the neural foramena

Question 21

Characteristics of discogenic pain?

Answer 21

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)

Question 22

Presentation of facet arthropathy?

Answer 22

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