Back Pain

Question 1

Go through the back Exam, outline specific tests you could do in a GP setting?

Answer 1

1. Inspect
2. Walk - walk back on your heels/toes

• L5 on heels
• S1 on toes

1. Copy movements - bend down touch and back and side to side Flexion, extension, rotation, lateral flexion (write degrees on motion)
2. Rotation
3. Push down does it hurt? a. Quadrant test - extension and rotation, press facet joints in lumbar spine (useful to what is going on) - maybe not in actual exam
4. Schobers test (measure the back)
5. Seat on bed - lift up know if you get pain (calf pain doesn’t mean much if you stretch the scitic nerve) a. Striaght leg raise - point of pain and dorsiflex then pain is worse its more likely from back b. Slump test (more sensitivity) - lifting up head. More useful
6. Pain when pushing.

• Palpating the back, lie down. Lean forward on thable like that.
• Top of iliac spines, know what you’re pushing.
• Palpating bone then 1.5cm lateral. (facet joints)

1. Neurological examination. - supine can do it too.

Question 2

Classification of Back Pain based on time frame?

Answer 2

• Acute
• <4weeks Subacute 4-12weeks
• Chronic >3 months

Question 3

What are the red flags for Back Pain?

Answer 3

TUNA FISH

• Trauma + thoracic back pain
• Unexplained LOW (+ constitutional signs) + unremitting pain
• Neurological signs = incontinence, saddle anaesthesia, weakness, Δ sensation …
• Age >50, <20
• Fever
• IVDU + immunosuppression (+ spinal anaesthesia)
• Steroids + spinal tenderness (+ structural deformity)
• Hx neoplasia Sclerotic = breast (± mixed), prostate, lung Lytic = thyroid, melanoma, RCC

Question 4

Outline the Indications for Imaging in Back Pain?

Answer 4

• Radiograph
  
  • Immediate + ESR
    
    • RF for cancer or strong clinical suspicion
  • Delayed after trial therapy
    
    • weaker RFs for cancer (unexplained weight loss, >50years)
    • ankylosing spondylitis (morning stiffness, buttock pain, young)
    • compression fracture (OP, older, (>65 or >75 for men), trauma)
• MRI
  
  • Immediate
    
    • RF for spinal infection (IVDU, fever)
    • cauda equina
  • Delayed after trial therapy
    
    • radiculopathy (dermatomal or + straight leg raise)
    • RF for spinal stenosis

Question 5

Outline some red flag conditions for back pain

Answer 5

• Cauda Equina syndrome
  
  • compression of spine below L2
  • incontinence and urinary retention
  • saddle anaesthesia
• Ankylosing Spondylitis
  
  • autoimmune in young men,
  • improves with exercise worse in the morning
• Fractures
  
  • tenderness on palpation
  • generally older people
• Tumour
  
  • primary or secondary (weight loss, fever, PMHx)
• Infection (IVDU/fever) - pain severe

Question 6

Outline treatment of Back pain

Answer 6

1. reassure - encourage graded resumption of activity. Hurting not harming.
2. 1st choice pain management for paracetamol locally applied heat review in 1-2 weeks
3. exercises and physiotherapy.

Question 7

What are yellow flags in back pain?

Answer 7

• psychosocial factors that are causing the back pain to persist, e.g. depression - occupation

Question 8

What are some probable causes of back pain?

Answer 8

• Nonspecific musculoskeletal stain
  
  • Complex, avoid discussion - pathology is not well understood.
• Can have herniation without pain or none with pain.
• Sciatica
  
  • Trapped nerve root, generally L5/S1.
  • Can just be in the leg
• Spinal canal stenosis
  
  • Older age group
  • narrowing from processes (degeneration, OA, hypertrophy of joints)
  • Leg pain and pseudo-claudication (neurogenic)