Year 2 - Week 6 - Back Pain

Question 1

What does non-specific mean in terms of diagnosis?

Answer 1

There is no identified serious underlying cause

Question 2

What associated symptoms can you get with back pain?

Answer 2

Morning stiffness, leg pain or weakness, muscle spasm, numbness or paraesthesia, weight loss

Question 3

What are the red flags for back pain?

Answer 3

TUNAFISH

Trauma
Unexplained weight loss
Neurological symptoms/signs
Age >50
Fever
IV Drug Use
Steriod Use
History of Cancer

Question 4

Which red flag diseases should you be mindful of with a back pain presentation?

Answer 4

Cauda Equina Syndrome
Spinal Fracture
Cancer
Spinal Infections

Question 5

Which red flag symptoms may suggest cauda equina syndrome?

Answer 5

Bilateral sciatica.

Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.

Difficulty initiating micturition or impaired sensation of urinary flow - if untreated this may lead to irreversible urinary retention with overflow urinary incontinence.

Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence.

Perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia).

Laxity of the anal sphincter (consider an assessment of anal tone but note that this does not need to be performed in primary care)

Erectile dysfunction.

Question 6

What signs and symptoms may be present in a spinal fracture?

Answer 6

Structural deformity of the spine
Tenderness of the vertebral body
Possibly overlying contusion/abrasion

Question 7

What are the red flag symptoms for cancer within the spine?

Answer 7

Gradual ‘insidious’ onset
Thoracic back pain
Character of the pain - rest pain, night pain, pain worse on straining/sneezing
Localised tenderness
Symptoms which do not improve with therapy
Unexplained weight loss

Question 8

What are forms of arthritis that usually strike the bones in your spine and nearby joints called?

Answer 8

Spondylarthropathies

Question 9

What are red flag symptoms for infections of the spine?

Answer 9

Fever.
Tuberculosis, or recent urinary tract infection.
Diabetes mellitus.
History of intravenous drug use.
HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.
Pain at rest.
Raised inflammatory markers

Question 10

What is cauda equina syndrome?

Answer 10

Compression of the cauda equina (nerve roots caudal to termination of the spinal cord)

Question 11

Why does cauda equina syndrome need immediate treatment?

Answer 11

Because symptoms can progress rapidly and cause permanent disability - therefore surgical decompression needs to happen asap

Question 12

What is ankylosing spondylitis?

Answer 12

Ankylosing spondylitis (AS) is a long-term condition in which the spine and other areas of the body become inflamed.

Question 13

What are the S&S of ankylosing spondylitis?

Answer 13

Inflammatory back pain (so worse in the morning or at rest, and improves with activity).
Usually Ps <35years
May have sciatica +/- diffuse pelvic or buttock pain

As it progresses:
- Reduced spinal flexion & chest expansion
- Extra-articular features - enthesitis, psoriasis and uveitis

Question 14

Which antigen is ankylosing spondylitis associated with?

Answer 14

HLA-B27 (90% if Ps)

Question 15

What differentials are there for ankylosing spondylitis if the peripheral S&S are more dominant than the axial?

Answer 15

Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis

Question 16

What is Sciatica?

Answer 16

Pain in the distribution of the sciatic nerve (L4-S1)

Question 17

What is usually the cause of sciatica?

Answer 17

Usually inflammation or compression of the L4-S1 nerve roots

Question 18

What are yellow flags in terms of back pain?

Answer 18

Signs that a patient may develop chronic back pain. They include:

Low mood
Social withdrawal/isolation
Belief than pain equals harm
Fear-avoidance behaviour
Sickness behaviours
Somaticisation tendency
Poor job satisfaction
Issues at work
Poor social/family support
Overbearing family
Financial issues
Issues with benefits
Presence of compensation claims

Question 19

How do the patient’s beliefs abot their back pain factor in predicting their prognosis?

Answer 19

Whether they believe there is a serious underlying cause that is being missed - can lead to unnecessary investigations.

Belief that pain = damage - therefore they are wary about performing exercise for fear of causing further damage. For most Ps the opposite is true.

Patients who regard treatment as a passive process are less likely to have a favourable prognosis compared to those who actively participate.

Question 20

What is the relationship with mental health and back pain?

Answer 20

Strong links - Ps with existing depression and/or anxiety are at higher risk of developing chronic back pain.

Back pain can also exacerbate existing mental health issues = or contribute to their development.

Question 21

Which screening tool is used for yellow flags in back pain?

Answer 21

Keele STarT Back Screening Tool

Question 22

What numbers indicate low and medium-high risk onthe STarT Back Screening Tool?

Answer 22

<3 = low risk
= or > 4 = medium - high risk (depending on sub-score from 5-9)

Question 23

Why do we not image Ps with uncomplicated lower back pain in the absence of red flag symptoms?

Answer 23

There is good evidence that it does not improve outcomes
It may subject the patient to unnecessary radiation (depending on modality used)
It may lead to unnecessary further investigation of incidental findings
It adds additional unnecessary cost and workload to the health system
Incidental findings may lead to worry/concern from patients (which may impact beliefs as discussed in yellow flags section)

Question 24

What proportion of asymptomatic 50 year olds will have evidence of disc degeneration on spinal imaging?

What would this be in asymotomatic 20 year olds?

Answer 24

80% would have disc degeneration
60% would have disc bulge
32% would have facet joint degeneration

Asymptomatic 20 year olds:
37% would have disc degeneration
30% would have disc bulge
4% would have facet joint degeneration

Question 25

What non-pharmalogical interventions are recommended by NICE for treament of back pain?

Answer 25

Return to work programmes
Group exercise programmes
Manual therapies (massage, manipulation)
Psychological ytherapies (CBT)

Question 26

What non-pharmalogical interventions are not offered for back pain?

Answer 26

Orthotics
Acupuncture
TENS
Electrotherapies

Question 27

What pharmalogical interventions are recommended by NICE for back pain?

Answer 27

Oral NSAIDs - use at lowest effective dose for shortest duration with gastroprotection.

Weak opiods (codeine) can be considered when NSAIDs are CI, ineffective or not tolerated. Should be used for acute, not chronic , back pain.

Question 28

Which pharmacological intervention is conflicting guidance given about from NICE for back pain?

Answer 28

Benzodiazepines - listed as short-term option for muscle spasm in acute back pain, but not mentioned for lower back pain generally and are specifically advised against for sciatica.

Question 29

Which pharmalogical interventions are explicitly not recommended by NICE for back pain?

Answer 29

Paracetamol - no better than placebo
Opiods - not for chronic back pain
Gabapentinoids
SSRIs / SNRIs / Tricyclics - recent guidance explicity advises against their use