Symposium 1: Back Pain

Question 1

What happens to the spine with age?

Answer 1

• Discs lose water and lose strength and become thinner
• Vertebral endplates and underlying bone structure loses strength
• Repetitive loading/trauma can result in annular tears in the discs
• Dryer, weaker discs result in slacker ligaments
• Spine is less stable
• New bone grows (osteophytes) to try to stabilise the spine
• Increased load over the facet joints

Question 2

What are the clinical implications of back pain?

Answer 2

• Loss of movement
• Muscle weakness and wasting
• Both due to ‘fear avoidance’

Question 3

What risk factors determine back pain?

Answer 3

• Genetics
• Environment
• Body weight
• Muscle strength
• Mechanical loading strengthens vertebral bodies and increases the water content within discs

Question 4

What are the occupational risk factors for LBP?

Answer 4

• Heavy physical jobs
• Lifting
• Driving to work
• Previous episodes of LBP
• Mental health
• Posture- laptops, seating, desk set-up

Question 5

What are the features of simple back pain?

Answer 5

• First episode often sudden onset while lifting/twisting/turning
• Recurrent episodes with decreasing inter-episode frequency
• Variable pain related to position/posture
• Better lying flat
• May radiate to buttock and leg
• Often worse at the end of the day and better with lying down/resting

Question 6

What is the new thinking around LBP management?

Answer 6

Exercise, usually no imaging, activity, light duty option

Question 7

When would you perform imaging?

Answer 7

Only if it’s going to change your management plan.

Question 8

What percentage of people over 65 have changes on x ray?

Answer 8

100%

Question 9

What are the features of sciatica?

Answer 9

• Sciatic nerve – L4 to S3
• Pain radiating from the back to the leg below the knee
• May be associated with pins and needles in leg
• May be associated with numbness and weakness
• Commonest neurological sign is loss of ankle jerk
• Commonest weakness is foot drop

Question 10

What are the red flag symptoms for back pain?

Answer 10

• Age (young or old) at first onset
• History of carcinoma
• Weight loss
• Constant (24h) pain > 1 month
• No response to treatment
• Pain worse at rest
• History of IV drug abuse or HIV positivity
• UTI or other infection

Question 11

What are the symptoms of inflammatory back pain?

Answer 11

• Insidious onset
• Nocturnal pain with marked early morning stiffness
• Better with exercise (complete opposite of mechanical back pain)
• Worse with rest
• Family history
• Buttock pain

Question 12

What are the features of ankylosing spondylitis.

Answer 12

• affects young men
• pain and stiffness in the spine
• large joint oligoarthritis
• enthesitis
• iritis
• FH of associated diseases (IBD, psoriasis)

Question 13

What are the risk factors for osteoporosis?

Answer 13

• Age
• Female (oestrogen)
• Smoking
• Steroids
• Alcohol
• Family history

Question 14

What is osteomalacia?

Answer 14

Bone softening due to lack of Vit D/calcium.

Question 15

What is Paget’s disease?

Answer 15

Cause by raised alkaline phosphatase - causes and increase in bone density and makes patient more vulnerable to fractures. Can cause spinal stenosis.

Question 16

What are the features of neurologic claudication (spinal stenosis)?

Answer 16

• Usually a history of chronic back pain
• Bilateral leg symptoms - weakness, tingling, sometimes described as ‘cold water running down the legs’
• Leg symptoms come on while standing or walking
• Relieved by rest (sitting) or leaning forward
• Distinguish from intermittent claudication by normal peripheral pulses and worse walking downhill