Back Pain

Question 1

Briefly explain the burden of baack pain

Answer 1

• Very common disease which has the highest economic burden of any disease.
• For the patient is causes financial burden, insomnia and psychological effects

Question 2

What is the definition of chronic back pain and some differential diagnosis?

Answer 2

CBP - pain for 3+ months.
- Most chronic back pain is mechanical (97%), referred or systemic (infection, malignancy or inflammatory) A lot of isolated back pain goes unexplained

Question 3

Describe the clinical presentation and causes of non-specific low back pain (mechanical back pain)

Answer 3

• Onset at any age. Pain generally worse with movement or prolonged standing, gets better with rest. Often EMS for less than 30mins.
• Causes include:
• lumbar strain/sprain (most common. Muscle spasm usually settling in 24-48 hours),
• Degenerative discs (spondylosis. Pain worse with flexion, sitting or sneezing)
• Degenerative facet joint disease (localised and worse with extension)
• Disc prolapse/spinal stenosis
• Compression fractures.

Question 4

What is the management of non-specific lower back pain?

Answer 4

• Keep diagnosis under review and give reassurance!
• Promote self management with pain killers (non-opioids) and stay active!
• Exercise programmes and physio.
• Do not give injections, traction or lumbar support.

Question 5

Describe the clinical features of disc prolapse (herniated nucleus pulposus)

Answer 5

• Often presents with acute pain which is worse when coughing.
• If disc prolapses to the side then is can cause unilateral sciatica.
• There is a positive straight leg raising test and reduced reflexes.
• Most resolve spontaneously within 12 weeks but if not then investigate further. Very few need surgery.

Question 6

What are the symptoms of cauda equina syndrome?

Answer 6

Spinal cord ends at L1/2. Compression occurs commonly at L4/5
- Bilateral sciatica (unilateral indicates lateral disc hernia),
- Saddle anaesthesia,
- Bladder or bowel dysfunction with reduced anal tone,
- Change in erection/vagina sensation,
- Weakness

Question 7

Describe features of spinal stenosis

Answer 7

• Anatomical narrowing of the spinal canal which can be congenital and/or degeneration.
• Often presents with bilateral claudication in the legs/calves which is worse when walking or resting in a flexed position.
• Investigations include X- ray and MRI

Question 8

What is Spondylolisthesis?

Answer 8

• A slip of one vertebrae over the other which can occur due to a pars interarticularis defect. Pain may radiate to the posterior thigh and become worse with extension

Question 9

Describe features, diagnosis and treatment of a compression fracture

Answer 9

• Often occur in elderly patients who have risk factors such as steroid use or smoking or osteoporosis.
• Presents with severe sudden onset of pain which radiates in a belt around the chest/abdomen. Should settle within 3 months but can result in kyphosis.
• Diagnosis is via X-ray and DEXA scan
• Treatment is either conservative with analgesia, calcitonoin or vertebroplasty (cement) or kyphoplasty (billon)

Question 10

What are the possible causes of refferred back pain?

Answer 10

This can occur from retroperitoneal structures such as:
- Aortic aneurysms (Pulsating abdo mass which if ruptures can be fatal)
- Acute pancreatitis (epigastric pain which is better when leaning forward)
- Peptic ulcer disease (epigastric pain with meals, vomiting, melaena)
- Acute pyelonephritis or renal colic ( history of UTIs or stones)
- Endometriosis.

Question 11

Describe features, investigations and treatment for infective discitis

Answer 11

• Typically occurs in immunosupressed, diabetes or IVDU patients. It can present with fever, weight-loss, night pain and pain at rest (constant).
• Investigations include bloods (FBC, ESR, CRP, blood cultures), X ray or MRI (no disc space will be seen), radiological guided aspiration.
• Most commonly caused by staph aureus and needs treatment with IV antibiotics +/- surgical debridement.

Question 12

What are the common tumours which metastases to the spine and how does it present

Answer 12

LP Thomas Knows Best - Lung, Prostate, Thyroid, Kidney, Breast.
It can present with constant pain which is worse at night and systemic symptoms. Investigate via X-ray, MRI and bone scan

Question 13

What are the red flag symptoms for back pain?

Answer 13

• New onset of age <16 or >50.
• Pain following significant trauma,
• Previous malignancy,
• Systemic symptoms,
• Previous steroid use,
• IVDU/immunosupression,
• Urinary retention,
• Night pain,
• Thoracic spine pain.

Question 14

What are the red flag signs for back pain?

Answer 14

• Saddle anaesthesia,
• Reduced anal tone,
• Hip or knee weakness,
• Neuro defect,
• Progressive spinal deformity