Back Pain

Question 1

What are red flags for back pain?

Answer 1

Age <20 or >55
Constant or progressive pain
Night pain
Bladder/bowel symptoms
History of TB/malignancy/HIV
Pain in thoracic spine
History of significant trauma
Saddle anaesthesia
Point midline tenderness on palpation

Question 2

What are the symptoms of mechanical back pain?

Answer 2

Pain in lumbosacral region
20-55 yo
Sudden onset when lifting
Pain varies with posture activity and time
Pain can spread to buttocks and thigh

Question 3

What are signs of mechanical back pain?

Answer 3

Palpable muscle spasm- causes localised pain or tenderness

Question 4

What is the management of mechanical back pain?

Answer 4

Simple analgesia
Keep active
Physio
90% recover in 6wks

Question 5

What is acute lumbar disc prolpase and nerve entrapment?

Answer 5

Nucleus pulposus herniates into spinal canal
Can be caused by lifting or even sneezing

Common sites L4/5 or L5/S1

If herniation is severe it can compress nerve routes

If herniation central not lateral- can cause cauda equina

Question 6

What are symptoms of disc prolapse and nerve entrapment?

Answer 6

Trigger event known
Post event pain and unable to straighten
Pain worse on coughing/straining
Pain radiates into buttock within a few hours and to thigh within few days

Radicular pain present

• severe pain and paraesthesia
• numbness in one leg due to compression of sciatic nerve root

Clumsiness of foot

Bladder/bowel symptoms

Question 7

What are signs of disc prolapse and nerve entrapment?

Answer 7

Walk with flexed leg/obvious scoliosis
Palpable muscle spasm
Straight leg test- 30 degrees causes pain
Femoral stretch test positive

Neuro exam

• muscle weakness
• loss of sensation
• diminished reflexes at level

Must rule out CE

• DRE- no sensation and loss of anal tone
• signs of bladder retention
• sensation in saddle area decreased

Question 8

What is the management of disc prolapse and nerve entrapment?

Answer 8

Initially conservative

• anti inflammatories and bed rest for 2wks
• reduces herniation in 90%

If symptoms persist at 2wks

• epidural injections for radicular symptoms
• MRI and surgery referral
• physio

For cauda equina
-Emergency MRI and surgery to prevent long term bladder/bowel problems

Question 9

What is lumbar canal stenosis?

Answer 9

Caused by degeneration of spine

• facet joint hypertrophy
• ligamentum flavum hypertrophy
• disc degeneration
• OA

Stenosis of lumbar canal compresses cauda equina roots causing symptoms

Question 10

What are symptoms of lumbar canal stenosis?

Answer 10

Posterior aching pain in legs when walking
Pain recovers slowly on sitting/bending forwards

Numbness, stiffness and weakness in one leg
Symptoms vary

Question 11

What is the management of lumbar canal stenosis?

Answer 11

Conservative- activity modification or physio

Surgery

Question 12

What is spondylolisthesis?

Answer 12

Displacement of vertebra anteriorly or posteriorly on the vertebra below it

Mostly between L4/5 or L5/S1

Step in spine on palpation

Question 13

What are the causes of spondylolisthesis?

Answer 13

Spondylolysis
Dysplasia of lumbosacral facet joints
OA of facet joints
extreme athletes

Question 14

How is spondylolisthesis managed?

Answer 14

Conservative unless young or disabling symptoms then surgery