Rheuma: Low Back Pain Flashcards
risk factors for low back pain
- age
- gender
- social class
- occupation and level of activity
- height
- weight
- psychological and psychosocial factors including attitudes to work and income
how can you define low back pain?
pain and discomfort below the costal margin and above the inferior gluteal folds, with or without leg pain
how can low back pain be classified?
- aetiology
- pain localisation/radiation
- time course of the pain
how can the degree of aetiology be classified?
into serious and nonserious
what is non-serious low back pain?
one which usually goes away with either rest or exercise
classification of low back pain according to site
- no radiation
- radiates above the knee
- radiates below the knee
- radiates below the knee + neurological signs
what does radiation below the knee means?
more likely that a nerve root has been involved and irritated
how does a simple back ache present?
- patient is 20-55yo
- pain in the lumbrosacral, buttocks or thighs
- pain related to activity (mechanical pain)
- patient is otherwise well
characteristics of mechanical pain
- worse with activity
- relieved by rest
characteristics of nerve root pain
- unilateral leg pain worse than the back pain
- radiates to the foot or toes
- numbness and paraesthesia in the same distribution
- local neurological signs
which test reproduces the leg pain?
straight leg raise test
major categories of LBP
- degenerative
- traumatic
- metabolic
- infectious
- inflammatory
- neoplastic
- psychogenic
- referred
example of metabolic bone disease
Paget’s disease of bone
which infections can cause low back pain?
- TB
- brucellosis
- other bacterial infections
what are some specific mechanical lumbar spine problems
- prolapsed intervertebral disc
- facet joint problems
- spinal stenosis
- lumbar instability and spondylolithesis
- sacroiliac problems
what are problems that spinal stenosis can cause?
- cauda equina
- simian stance
- feel pain walking downhill rather than uphill
red flags in the history
- age not in the range mentioned above
- cause is violent trauma
- upper back problem or upper lumbar pain
- pain is persistent, progressive, not relieved by rest and worse in bed
- severe morning stiffness
- associated cancer symptoms
- past medical history of imp medical conditions or steroid use
which medications increase the chances of having spinal fractures
steroids
red flags in clinical examinations
- deformity (espec if painful)
- severe and symmetrical restriction of spinal movements
- saddle anaesthesia
- severe and progressive neurological signs, often with muscle wasting
- multiple levels of root signs or bilateral root signs
important things to distinguish in examinations
- spinal or non-spinal pain
- mechanical or non-mechnical pain
- presence or absence of neurological feature
radiological investigations for LBP
- plain xrays
- CT
- MRI
- isotope bone scans
- bone densitometry
things to look out for in radiology
- narrowing of disc spaces
- osteophyte formation
- inflammation on MRI
- fusion of the longitudinal ligaments in xray
- bone marrow oedema on MRI
how can you diagnose a herniated disc?
CT/MRI
how to check for bone destruction?
nuclear medicine
how positive/negative blood results useful
positive - yes
negative - no
investigations for LBP
- ESR
- CRP
- FBC
- urinalysis
- LFTs
- calcium/phosphate
- serum protein electrophoresis
- renal function
what does an elevated alkaline phosphatase mean?
suggests Paget’s disease
drug therapy in rheumatology
- paracetamol
- NSAIDs
- weak opioid compounds
- muscle relaxant
how do you prescribe analgesics?
at regular intervals
NOT PRN
what should not be recommended as treatment for back pain?
bed rest
advice on staying active
- regular exercise
- increase activity over a few weeks
- if they work, recommend that they continue work
non-pharmacogical treatment
- physiotherapy
- transcutaneous electrical nerve stimulation
- acupuncture
- manipulation
- epidural steroid injection
what are yellow flags
these slow down the patient’s recovery by a long shot
yellow flags in LBP
- inappropriate beliefs about back pain
- inappropriate back behaviour
- work-related problems or compensation issues
- emotional problems
what are the options in back pain diagnostic triage
- possible serious spinal pathology
- nerve root problem
- simple backache
