Back pain

Question 1

What are the 3 clinical classification of lower back pain ?

Answer 1

0 simple back pain / non -specific (Mechanical ? ) 95% - main type

0 Back pain - with nerve root pain - 4 % of pop

0 Serous spinal pathology - 1 % of pop

Question 2

What is mechanical back pain ?

Answer 2

Pain originates from joints , bones or soft tissues in and around spine.

considered non -specific MSK pain - strained muscles , ligaments in back

DIAGNOSIS -

0 no specific cause found
o unilateral dull pain
o may radiate to buttocks but not beyond knee ( this more suggestive of sciatica )
o patient is systemically well

0 Typically caused by : 
       1. heavy 
          lifting 
       2. poor 
           posture 
      3. incorrect 
          bending 
          etc. 
       4. poorly 
           designed 
           seating 
0 Pain linked to :
o position - better or worse in certain positions

o activity - worse with physical activity - especially in acute phase - first 3 months.

• Usually started to get better within a few weeks.
  o X -rays of back not routinely done for non -s pecific back pain

people low back pain - always exclude sciatica , inflammatory features & serious spinal pathology.

1st apponitment - X - ray not offered , physiotherapy , manual therapy - for non -specific pain.
after one week - if no better - physio / manual can be offered.

• if inflammatory component - refer to rheumotology - after ESR , CRP investigation.

Question 3

Categories of back pain - not clinical classifications ?

Answer 3

0 Degenerative

0 Mechanical

0 Infections

0 cancer

0 Inflammatory disorder - ankylosing sponlitis ?

0 Spinal epidural hematoma

Question 4

Red flags - things to look out for - with lower back pain - TUNA FISH

Answer 4

T U N A F I S H

T - Trauma

U - unexplained weight loss - suggestive of possible cancer

N - Neurological symptoms -

o sensory loss,
o pain
o weakness in legs

o saddle anesthesia ( loss of sensation in the perineum(btw anus & vulva/scrotum, buttocks, groin area )
o bowel, bladder, sexual dysfunction
( LAST 3 - indicative of Cauda Equina - surgical emergency - ASAP MRI.

A - Age - over 50 - increased risk of cancer

F - Fever - possible infection ?

I - Infection 
    o Fever 
    o intravascular drug use 
    o immunocompromised - 
    HIV , 
    immunosuppressant use 
    o UTI
    o TB

S - Steroid use - secondary osteoporosis

H - History of cancer
particularly - prostate,
breast, lung & kidney

CANCER
SPINAL FRACTURE - STRUCTURAL DEFORMITY
GAIT DISTURBANCE 
     o tripping over - 
        L5 damage due 
        to weakness of 
        extensor hallicus 
         longus - bizarre 
         gait pattern. 
      o If they limp - 
         look at hip and 
         rule out hip 
         issue
       o Ataxia - group 
          of disorders - 
          disturbance in 
          balance , co- 
          ordination & 
          speech - upper 
          neurone ?
- Systemically unwell

Question 5

Treatment of non specific MSK pain ?

Answer 5

Increase mobility - important not to be immobile ( will make it worse )

• apply heat or cold
• massage
• physical therapy
• Chiropractor

Medication -

NSAIDS
o e.g ibuprofen or Naproxen - first
line - lowest dose possible
* offer gastroprotection with NSAID use.

NSAID contraindiacted , ineffective - not tolerated
o codeine with/or without paracetamol .
( take into account risk of opiod dependence , side effect - constipation )

0 Opiods not use for chronic pain.
PARACETAMOL IS NOT GOOD ENOUGH ALONE.

0 Muscle spasm present - consider short course of benzodiazepine - e.g diazepam - 5 days etc.

(Muscle relaxants e.g Cyclobenzapine
Tizanidine) -NOT MENTIONED IN NICE GUIDELINES - OSMOSIS

Usually resolved within 2 -3 weeks
( if not may have a specific cause )
Safety net - if not better within 3 -4 weeks seek follow up.

,

Question 6

Causes of mechanical pain ?

Answer 6

Disc Herniation
   - risk in 
     spondylosis 
     can happen 
     in healthy - 
     who lift heavy 
    object ro 
    trauma
- cause Lumbarsacral radioculopathy / Sciatica - due to irritation or compression of nerve root. 

o shooting pain - down back below knee.- unilateral  ( posterior longitudinal ligament located - posteriorly to spine -------------------> nucleus pulposus - will herniate posteriolaterally as a result compressing / irritation the nerve root on that side ( not both ) - so unilateral symptoms.

compression of nerve root below e.g :
o L3 -L4 IV DISC HERNIATION compression of L4 NR
test
squat & rise

o L4 -L5 IV DISC HERNIATION compression of L5 NR
test - heal walk

o L5 -S1 IV DISC HERNIATION compression of S1 NR
test - toe walk

positive test - indicate herniation

Straight leg raise test — patient lies down – one leg raised unitl they complain of pain( shooting pain down leg)- (btw 30 -70 degrees )positive test = radiculopathy

• should be followed up by Lumbar X ray ( shows loss of disc height - degeneration )

however should be followed by Lumbar MRI for disc herniation.

TREATMENT

ACUTE

• NSAIDS
• PHYSICAL THERAPY
• CHIROPRACTER

SEVERE
- surgery may be needed

Question 7

Infection - lower back pain ?

Answer 7

CAUSES

• vertebral osteomyelitisSYMPTOMS
  • Pain - pinpint & well localised
  • Fever
  • pain
• Spinal epidural abscess

SYMPTOMS

• back pain
• fever
• neurological symptoms

High index of suspection needed - as not all 3 symptoms always how up.
CAUSATIVE ORGANISMS

• S. aureus
• Streptococci
• enteric bacilli
  -Pseudomonas aeruginosa - common IV drug users
• mycobacterium TB - if causes osteomyeltits - called pott’s disease

SPREAD

o Haematogenous- pathogen enters blood from distant site of infection ———-infects the vetebrae
almost always leads to discitis (infected disc)

discitis —.> infection can spread from disc to epidural space causing ———> spinal epidural abscess (SEA)

SEA - can also happen on its own.
(infection in epidural space - btw veterbrae & membrane lining spinal cord
- can grow big compress adjacent nerve root or spinal cord ———-> neurological symptoms.

o directly innoculated into veterbrae during trauma/ surgery

RISK FACTORS FOR BOTH

• UTI
• immunosupression e.g chronic steroid use & HIV
• IV drug use
• endocarditis - inflammation of endocardium - inner lining of heart.
• indwelling devices e.g central venous line
• diabetes

TEST -
0 CRP - C reactive protein ( produced by liver in response to inflammation) - indicates success of treatment - rises & falls quickly

& ESR ( erythrocyte sedimentation rate - not as commonly used - CRP used instead )

0 FBC - check for leukocytosis
( CBC - complete BC - another name)

blood & urine cultures

VO - Biopsy ( find CO)

imaging

MRI better than x ray

vertebral osteomyelitis + discitis - oedema of vertebral body & destruction of intervertebral space.

abcess - fluid filled sac - appears brighter with contrast.

TREATMENT

0 antibiotics
0 surgical decompression & drainage - for abscess with neurological deficits - most be done o prevent permanent paralysis
- if now deficit - sample of abscess taken- then antibiotic tailored to result.

VO - caused TB - potts disease - treated with R I P E regimine

R - rifampin

I - Isoniazid

F- Pyrazinamide

E- ethambutol

for 2 months

then R & I for the rest of the 9 -12 months

slowly progressing infection - does not cause symptoms unitl extensive involvement e.g abcesses - extensive spread
( spinal debridement - may be needed- removal of infected tissue from spine )

Question 8

Spinal epidural haemotoma

Answer 8

0 Bleeding in epidural space

CAUSES

• Disc herniation
• recent surgery
• Trauma
• bleeding disorder / anti- coagulation therapy

SEVERE PAIN & well localized

o can compress adjacent nerve root & spinal cord

TEST

CBC - thrombocytopenia
- PT - prothrombin time( asses for coagulation problem ) .

DIAGNOSIS

MRI - sac of blood
o can extend across multiple spinal levels - get MRI of entire spine

TREATMENT

0 Surgical decompression - as soon as possible

0 problem with coagulation —> give fresh frozen plasma

Question 9

Vetebral compression fractures – lower back pain

Answer 9

Imaging - X - ray , Ct , MRI (MRI - can distinguish btw acute & chronic VCF )

bone density study should be look at.

TREATMENT

NSAIDS
Biphosphonates - management of osteoporosis symptoms.

Question 10

Cancer - Lower back pain ?

Answer 10

metastatic - cancer has spread from elsewhere to epidural space , veterbral marrow

common cancers that spread to spine :
o Prostate
o Breast
o Kidney
o Lungs

SYMPTOMS

o pain
o Fever
o night sweats 
o focal neurological symptoms
o unexplained weight loss
o not an improvement after 4-6 weeks of conservative management.

PAIN PATTERN

o constant 
o worse at night 
o not better with rest
o localized spinal 
   tenderness 

IMAGING

• MRI - to check for metastases

SUSPECT WHEN :

all of the above - others also :
o thoracic pain

Question 11

What is Cauda equina syndrome ?

Answer 11

Compression of cauda equina - compression of lumbar & sacral nerve rots after spinal cord ends.

SYMPTOMS

0 unilateral, or bilateral asymmetric sensory loss,
0 pain or weakness in the extremities,
0 loss of reflexes.
sudden unexplained bilateral lower-extremity weakness

THESE DIFFERIATE IT FROM LUMBARSACRAL RADICULOPATHY
0 saddle anesthesia

Bilateral sciatica.

0 bowel, bladder, or sexual dysfunction.

1. urinary hesitancy
2. urinary retention followed by overflow urinary incontinence
   diagnosis - bladder ultrasound ( see how much urine left in bladder after they relieve themselves -PVR - Post- void residual)

PVR -
normal - below 30 ml

above 100 ml - sig neurological compromise

- Fecal retention ---> followed by overfow fecal incontinence 

diagnosed by digital rectal exam
- diminished sphincter tone

male - erectile dysfunction.

TREATMENT

Surgery needed within 8 hours - to prevent permanent incontinence ( bladder stretches too much - never goes back ) - MUST NOT MISS - emergency MRI needed.

• WHEN PERSON COMES IN WITH BACK PAIN - make sure they can pass urine - if patient sent home - safety net e.g if you develop urinary hesitancy , saddle etc - come back )

Question 12

What is Conus Medullaris syndrome ?

Answer 12

Damage to Conus medullaris - most distal bulbous part of spinal cord.

similar to Cauda equina:
o saddle anesthesia
o bowel , bladder & sexual dusfunction.

Difference :
bilateral & symmetrical pattern
o urinary & fecal incontinence - early syndrome.

compression of this area - can damage corticospinal tract - upper motor neurone signs below level of lesion
    - Brisk , hyperactive reflexes
    - spasicity
    - extensor 
      plantar 
      response / 
      babinski 
      reflex

MANAGEMENT

• emergency MRI
• surgical decompression
• if cancer is the cause - IV corticosteriods.
  spinal radiation

Question 13

Inflammatory causes of back pain ?

Answer 13

Ankylosing spondylitis

commonly affects young males

• pain in spine , sacroiliac joint , entheses

PAIN PATTERN
o gradual onset
o improves with exercise 
o morning stiffness
o not improve with rest. 

EXTRA - ARTICULAR MANIFESTATIONS - ( means outiside of or other than a joint. -systemic
o uvetis
o Psoriasis
o Aortic root
dilation – increase risk of aortic dissection.

CBC / FBC - might show microcytic hypochromic anaemia -
CRP , ESR - maybe elevated - indicate inflammation
o positive for HLA B27 - almost all

IMAGING

X - ray , MRI of sacral iliiac joints.
see :
erosion
sclerosis
narrowing of joint space ( if they fuse - ankylosis )
- Bamboo spine - vertebrae abnormally connected together

TREATMENT
o anti-inflammatory E.G sulfasalazine

o tumor necrosis alpha inhibitors e.g. infliximab.

Question 14

Possible causes of back pain - not linked to spine / vertebrae ?

Answer 14

AAA - abnominal aortic aneurysm

vague back , flank pain

Pulsatile abdnominal mass

• person may become hypotensve due to blood loss

DIAGNOSIS
- abdominal ultrasound.

0 retroperitoneal hemorrhage, can develop :

• people on anticoagulation therapy
• had cannulation of the femoral artery during a cardiac catheterization procedure

lead to bilateral flank hematomas, - Grey-Turner sign.

0 aortic dissection

0 pyelonephritis,
0 renal colic

0 pancreatitis

0 pelvic inflammatory disease

0 endometriosis,

0 prostatitis.

Question 15

Degenerative back pain - lower back pain ?

Answer 15

Degenerative - age related wear and tear

   o Spondylosis ( 
      IV discs & 
      facets joint - 
      gradually 
      degenerate - 
      osteophytes ( 
      bone lumps - 
      can grow ) - 
      compress 
      adjacent 
      nerve roots - 
      causing 
      radicular pain 
      / 
      radiculopathy 
       ------ can also 
      narrow 
     intervetebral 
     foramen - 
     lumbar spinal 
     cord stenosis 

edema & 
swelling

( radiculopathy & lumbar spine stenosis - code - R & LSS)

 o Spondylolisthesis - vertebral body slips over body below it. 
CAUSES
    1. FACET -----> 
       FORWARD ( 
       osteoarthritis 
       of facte joint - 
       anterior slip )

    2. 
      degenerative 
      disc disease 
      DISC 
      DISEASE ------- 
      ------> 
      DORSAL 
     ( posterior slip 
     )
cause R & LSS

Diagnosis

MRI - pick up slipped disc , osteophytes , degeneration of IV disc

TREATMENT

• Pain management
• physcial therapy
• Surgery

Question 16

Causes of Lumbarsacral radiculopathy - Sciatica ?

Answer 16

Disc Herniation - most common

0 Spinal stenosis

0 Spondylolisthesis

Question 17

Signs of Sciatica ?

Answer 17

PAIN PATTERN

0 unilateral leg pain - radiates below knee to foot & toes
(Leg pain worse than back pain if present )

0 In a dermatome - single nerve root compression

• Numbness
• paraesthesia( tingling)
• muscle weakness
• loss of tendon reflex

0 Straight leg test - positive - worsening of pain felt with raising of straight leg - more severe compression symptoms .

0 Extensor plantar response - lateral part of sole ( feet ) stimulated ——> toes extend and fan outwards - suggest upper motor neurone
lesion.

rule out red flag symptoms - cauda equina etc.

BEWARE - if symptoms of sciatica - examine hip & knee - exclude disorders of the hip & knee - similar symptoms 
    o referred pain - hip 
       osteoarthritis
    o piriformis syndrome 
     - piriformis 
      compresses /. 
      irritates sciatic nerve- 
      covers sciatic nerve )
    o Aspectic necrosis of 
      femoral head. 
   o Trochanteric Bursitis 
      - inflammation / 
      swelling of bursa ( 
      fluid filled sacs near 
      joints )
   o non spinal causes of 
      back pain
   o spinal claudication
   o Myelopathy - severe 
      spinal 
      cord compression.  
      decompression 
      surgery needed. 
   o Sacrolitis.

Question 18

&

Answer 18

No red flags - same as non specific back pain

NSAID use
gastroprotection

DONT USE BENZODIAZEPINES WITH SCIATICA - used in non specific pain

• don’t use opioids , gabapentiniods , benzodiazepines
  ( if someone is already taking them discuss risks of continued use - discuss whether to continue - possible withdrawal symptoms.
• if not improvement or worsens within 1-2 weeks - follow up appointment

HIGH RISK OF POOR OUTCOME

o group exercise program

o physiotherapist referral - manual therapy

o promote & facilitate return to normal activities in daily living & work.

o exercise with/or without manual therapy

o cognitive behavioural therapy - if psychosocial barriers to recovery e.g incorrect ideas on what will make them better - e,g staying still & not doing anything will make the pain better.

Question 19

Referred pain - lower back pain .

Answer 19

If pain in several dermatomes - likely to be referred pain not radicular ?

Question 20

Difference btw Cauda equina

& Conus medullaris ?

Answer 20

Conus medularis - most bulbous distal part of the spinal cord

Cauda equina - collection of nerves roots at the distal end of spinal cord - horse tail appearance

Question 21

What is Lumbar spinal stenosis ?

Answer 21

narrowing of :

o central canal ( where spinal cord is located 0
o lateral recess - where nerve root exits central canal.
o neural foramen - foramen btw to spinal veterbrae,

CAUSES

0 spondylosis,

Positional pain - in terms of lumbar spinal stenosis pain caused by spondylosis-

neurogenic claudicaction / pseudoclaudiaction -
o neurogenic - arising in nervous system
o claudication - leg pain , heaviness, weakness wih walking

(pain induced by positions that extend spine e.g waking , standing erect - spinal canal , formina narrow on extension

relieve by positions that flex spine - sitting , leaning forward , lying down. ) - could ride a bike without pain )

0 spondylolisthesis,

0 trauma,

0  Paget disease of the bone - disruption to normal cycle of renewal of bone ( new bone replaces old bone ) - bones become weak or deformed .
Normally affects:
o Pelvis 
o spine 
o skull

Symptoms

o constant , dull bone pain
o joint pain , stiffness , swelling
o shooting pain - travels along body - numbness & tingling.

TREATMENT

• Biphosphonates
  
  • risendronate
  • Zoledronate
  • pamidronate
• pain relief - para , ibu

0 achondroplasia.

PAIN PATTERN - LSS

• bilateral - as central stenosis - affect both sides
• not follow dermatome pattern

TREATMENT -
o Physical therapy
o NSAIDS
o - if above does not work - Steroids
o Surgery - surgical laminectomy - removal of all lamina of veterbrae - creates space 

surgical laminotomy - part of lamina removed

Question 22

What is vascular claudication ?

Answer 22

Vascular - BV / blood

Claudication - leg pain

pain in the legs as a result of too little blood flow to this area.

CAUSES

• usually peripheral artery disease - arteries supplying legs / (limbs )narrow - usually bcc of atherosclerosis.

Question 23

Risk Factors for Chronicity

Answer 23

Previous history LBP

Total work loss (due to LBP) in last 12 months

Radiating leg pain

Reduced SLR

Signs of root involvement

Reduced trunk muscle strength

Poor physical fitness

Heavy smoking
Self- rated poor health

Psychological distress

Depressive symptoms

Disproportionate illness behaviour

Low job satisfaction
Personal problems

Medico-leqal proceedings

Question 24

What is Carpal tunnel syndrome ?

Answer 24

Carpal tunnel - borders - roof ( Flexor Retinaculum , concave / floor surface - carpal bones.

Pressure on a nerve (median nerve ) in the wrist due carpel tunnel swelling and squeezing down.

SYMPTOMS

o Tingling ( pins & needles ) , numbness , pain in  your heads and fingers.
o Weak thumb - difficulty gripping 

symptoms come and go - usually worse at night.

TREATMENT

0 self management - wrist splint in neutral position
(if they go to GP & the the splint helped - GP can offer steroid injection )
- avoid repetitive movements
- adaptation at workplace ( special mouse , keyboard )

0 Steroid injection - bring down swelling around median nerve - easing symptoms.

( CTS can come back after injection. )

0 Carpal Tunnel Syndrome - if CTS is getting worse & other treatments not worked

• usually cures
  CTS.
• Carpal tunnel cut - to stop compression on nerve

RISK FACTORS

0 overweight

0 pregnant
hobbies / Work - repeatedly bend your wrist or grip hard, e.g using vibrating tools
another illness arthritis, diabetes

0 parent, sibling with CTS

0 previously injured your wrist

( Linked to hormones - causes - The oral contraceptive pill
Hypothyroidism
Rheumatoid arthritis
Pregnancy
Cardiac failure
)

TEST

0 positive Tinel’s sign - lightly tap/ percuss over median / affected nerve - - if irritated nerve- tingling sensation occurs radiates outwards in median / affected nerve distribution.

Phalen’s sign - mauever - wrist flexed upside down 90 degrees (upside down T )
Positive - ellicit symptoms in median nerve distribution.

• nerve conduction studies can be used to confirm diagnosis ( e.g measures how fast electrical impulse moves through nerve - uses electrodes - as measures disatance and time - calculates speed )