Week 5 - F - Lumbar back pain, back pain red flags and structure of a vertebra

Question 1

What is a spinal vertebral bone composed of?

Answer 1

Vertebral body

Spinous process

Lamina - spinous to transverse process

Transverse process with superior and inferior articular processes

Pedicle - transverse process to vertebral body

A canal in the middle for the spinal cord

Question 2

Lower back pain is the second most common reason to seek medical help and is a symptom, not a diagnosis What is the difference between acute, subacute and chronic lower back pain?

Answer 2

Acute back pain is at presentation to 6 weeks

Subacute back pain is back pain lasting longer than 6 weeks

Chronic back pain is back pain lasting longer than 3 months

Question 3

Before meeting the patient: * Is the patient new? PMH? * Previous tolerance to pain. * Appointment type sought by patient (call-out, urgent etc..) What are the important questions to aks about the back pain? ie about when it started and what about now

Answer 3

Think about SOCRATES

• * When did it start?
• * How did it start?
• * Where did it start?
• * How bad was it at the start?
• * Where is it now?
• * How bad is it now?
• * When is it worst?
• * What makes it better?

Question 4

What are potential symptoms that can be associated with back pain?

Answer 4

Weight loss

Fever/temperature/sweats

Neck/arms/legs

Bowel/bladder

Question 5

What are red flags for back pain?

Answer 5

• New onset back pain in patients >50
• History of malignancy
• Constitutional symptoms - B type symptoms - night sweats, fever, weight loss
• Immunosuppresed status
• Nocturnal pain
• Morning stiffness
• Leg claudication or exercise related leg weakness/numbness - spinal stenosis

Question 6

There are different lumbar clinical syndromes ie Sciatica / Radicular pain Spinal stenosis Cauda equina syndrome

How will sciatica present?

Answer 6

This will present with leg pain that is greater than back pain

Typically sharp shooting pain worse on stretching and standing because the nerve is stretched

Better on lying with the knee flexed

Question 7

How will spinal stenosis present?

Answer 7

Usually will present with back pain that is greater than leg pain

There is usually pain on walking in one or both leg and pain on extension - spinal claudication

Question 8

How does cauda equina syndrome present?

Answer 8

Presents with back or leg pain

Bilateral sciatica

Bilateral leg weakness

Acute bladder / bowel incontinence and sensory loss on PR

Question 9

Disc prolapse can cause sciatica due to compression of the spinal nerve - this is a more typical radiculopathy What is the most common disc prolapse levels?

Answer 9

The most common levels for disc prolapse are the L4/5 vertebral level and the L5/S1 vertebral level

Typically severe pain on coughing, senezing or twisting a few days after back stain

Question 10

What investigations can be carried out, if required, in a person presenting with back pain?

Answer 10

Xray - quick and gives bony outlines

CT - good bone detail but only really used if contraindication to MRI in terms of spinal imaging

MRI - excellent soft tissue detail and bony detail isnt too bad but can give lots of false positive

Question 11

What level 1 drug does not show very good evidence for having effect in terms of analgesia for lumbar back pain? What is often given for the back pain if it is nerve pain related? What is given if it is inflammatory related?

Answer 11

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Question 12

What advice is given to patients with back pain on sitting posture and heavy lifting?

Answer 12

Proper sitting -

• * Hips should be flexed
• * Knees should not be extended
• * Back should not be overly arched
• * Max 30 minutes

Heavy lifting

• * Back kept erect
• * Knees bent
• * Pull object close on lifting