Back Pain and Sciatica

Question 1

what is buttock pain likely to be

Answer 1

muscular

Question 2

what is back pain going to below the knee likely to be

Answer 2

nerve- disc problem

Question 3

what are the general red flags for back pain

Answer 3

general

• failure to improve after 4-6 of conservative treatment
• unrelenting night pain or pain at rest
• progressive motor or sensory deficit

Question 4

what are the cancer red flags in back pain

Answer 4

cancer

• age > 50
• unintentional weight loss
• Hx of cancer
• pain at night and in recumbency

Question 5

what are the infection back pain red flags

Answer 5

infection

• fever/ chills
• recent infection
• immunosuppression
• IV drug use
• dental status
• foreign travel

Question 6

what are the cauda equina red flags

Answer 6

• Bilateral sciatica
• Urinary incontinence
• Leg weakness
• Absent anal tone
• Loss of perianal sensation

Question 7

what are the red flags for fracture in back pain

Answer 7

• age > 50
• osteoporosis
• significant trauma
• chronic steroid use

Question 8

what are the res flags for AAA in back pain

Answer 8

• age > 60
• abdominal pulsating mass
• pain at rest

Question 9

what root levels:

hip flexion

Answer 9

L2,3

Question 10

what root levels:

hip extension

Answer 10

L4,5

Question 11

what root levels:

knee extension

Answer 11

L3,4

Question 12

what root levels:

Knee flexion

Answer 12

L5,S1

Question 13

what root levels:

ankle dorsiflexion

Answer 13

L4,5

Question 14

what root levels:

ankle plantarflexion

Answer 14

S1,2

Question 15

what root levels:

foot eversion

Answer 15

L5,S1

Question 16

what root levels:

foot inversion

Answer 16

L4

Question 17

what are the MRC muscle power grades

Answer 17

0- complete paralysis
1- flicker of contraction possible
2- movement possible if gravity eliminated
3- movement against gravity but not resistance
4- movement possible against some resistance
5- power normal

Question 18

do you need to investigate all back pain

Answer 18

no 70-90% are innocent, resolve in a month with conservative Tx

Question 19

when should you do an x ray

Answer 19

do not x ray routinely
except in
- young men at SI joint to exclude ank spon
- elderly to exclude vertebral fractures, collapse, malignancy
-for deformity correction surgeries

Question 20

what are CT scans good for

Answer 20

bony pathology- trauma, tumours, infection)

• good for foreign bodies, implants
• spinal fusion planning
• if MRI contraindicated/ not available
• limited use in acute LBP unless red flags

Question 21

what is MRI good for

Answer 21

red flags in back pain= MRI
neurological signs/ symptoms= MRI

• soft tissue (inc tumours and infection)
• some sequences good for new fractures
• bone oedema/ microfractures

Question 22

what do radionucleotide scans show

Answer 22

increased bone turnover (tumours, pagets, fractures, osteomyelitis, ank spon, mets, osteoid osteoma)

Question 23

what does a PET scan show

Answer 23

increased uptake in high turnover areas

Question 24

when do you do lab tests in back pain

Answer 24

when red flags present

• malignancy (PSA, acid phosphate, monoclonal bands)
• infection
• metabolic causes (alk phos, Ca2+ etc)

Question 25

what is the treatment for back pain

Answer 25

aim to relieve pain and find underlying cause - explanation, reassurance, advice on activity and exercise, NO BED REST - WHO pain ladder - facet joint/ epidural injections for pain relief - complementary and alternative mechanisms (acupuncture, chiropracture, osteopath, massages, PHYSIOTHERAPISTS)

Question 26

what do you investigate back pain

Answer 26

no improvement in 4-6 weeks | any red flags

Question 27

when do you refer back pain

Answer 27

- intractable pain - serious pathology suspected or suggested on initial imaging - neurological deficit

Question 28

what are the risk factors for mechanical back pain

Answer 28

previous back pain heavy lifting/ frequent bending repetitive work with exposure to vibration

Question 29

how do you prevent mechanical back pain

Answer 29

education- lifting, turning etc, mental coping strategies, stopping smoking maintain physical activity

Question 30

what are the differential for causes of sciatic back

Answer 30

- root compression by degenerative causes (bone spurs, canal stenosis, spondylolisthesis, facet arthropathy) - root compression of sinister causes (tumour, fractures, TB) - root compression of sinister causes (tumour, #, TB) - root compression outside the spine (piriformis syndrome, endometriosis, pelvic disease, peroneal compression) - no root compression (arachnoiditis, peripheral neuropathies)

Question 31

what is piriformis syndrome

Answer 31

when the sciatic nerve goes through the piriformis muscle which can compress the nerve

Question 32

is sciatic permanent

Answer 32

no generally self limiting