Low Back Pain & Sciatica

Question 1

What should you ask a patient about onset of their back pain when taking a history?

Answer 1

• Was it sudden?

- Have you noticed a trigger?

Question 2

How may a patient describe the character of their back pain?

Answer 2

• Dull

- Stabbing

Question 3

Location and radiation of back pain is an indicator for the cause. TRUE/FALSE?

Answer 3

TRUE
e.g. if radiates to buttocks = muscular pain
If radiates to knee = more likely nerve pain

Question 4

After how many months would back pain be considered chronic?

Answer 4

> 3 months

Question 5

How should you ask about the intensity of a patients back pain (without using the 1-10 severity scale)?

Answer 5

Ask about what tasks it prohibits them from doing that they could do previously
e.g. climbing stairs

Question 6

What associated symptoms should you always ask about in patients with back pain?

Answer 6

Urinary symptoms
faecal symptoms (e.g. incontinence of both)

Question 7

What factors can potentially aggravate patients back pain?

Answer 7

• certain positions
• coughing, sneezing (increases intrathecal pressure on nerve roots)
• walking down stairs (due to walking on heel first)

Question 8

What factors can relieve a persons back pain?

Answer 8

• certain positions i.e. lying and standing usually better than sitting
• non-pharmacological methods - physio chiropractor
• analgesia

Question 9

What should be asked about in the systems review to check for causes other than mechanical back pain?

Answer 9

fever
weight loss
abdominal pain
cough/haemoptysis
dysuria/haematuria

Question 10

What parts of a PMHx (including surgery) should you specifically ask about when a patient has back pain?

Answer 10

• previous trauma
• previous operations e.g. on spine
• previous malignancy

Question 11

What parts of the social history are important when patients present with back pain?

Answer 11

• Occupation (type of work, level of activity during)
• Smoking
• Recreational drugs (e.g. steroids)

Question 12

Back pain can be referred from elsewhere. TRUE/FALSE?

Answer 12

TRUE

=> always check that a patient’s back pain is not referred pain

Question 13

What are the MAIN red flags of back pain?

Answer 13

• Pain at night OR at rest
• Failure of pain to improve after 4-6 weeks of conservative therapy
• Motor or sensory deficit

Question 14

What red flags of back pain and other risk factors may indicate cancer?

Answer 14

> 50 years old
unintentional weight loss
previous history of cancer
Night pain

Question 15

What symptoms and risk factors would indicate back pain is due to an infection?

Answer 15

• Fever/chills
• Recent infection
• Immunosuppression
• IV drug use
• Dental Status
• Foreign Travel

Question 16

What symptoms and risk factors would make you consider that a patients back pain is due to a fracture?

Answer 16

> 50 years old
osteoporosis (particularly females)
trauma
chronic steroid use

Question 17

What symptoms and risk factors indicate ower back pain is due to sciatica?

Answer 17

• bilateral sciatica
• urinary incontinence
• leg weakness
• Impaired anal tone
• loss of perianal sensation

Question 18

What signs and symptoms may indicate an AAA causing lower back pain?

Answer 18

> 60 years old
pulsating mass
pain at rest

Question 19

What other tests should be completed alongside a spinal examination?

Answer 19

Straight leg raise (testing hips)
Test muscle strength
Test sensation
Deep tendon reflexes
Standing on heels and then toes (whilst supported)
Lower limb assessment

Question 20

Investigations are often not required in patients with lower back pain. TRUE/FALSE?

Answer 20

TRUE

70-90% don’t require investigating as it will resolve with analgesia and activity

Question 21

Who should we X-Ray when they complain of back pain?

Answer 21

Young men - check SI joints for ankylosing spondylitis

Elderly patients - vertebral collapse, fracture, malignancy

Question 22

When is CT used to investigate back pain?

Answer 22

Limited use UNLESS RED FLAGS
=> looks for bone pathology- tumour, infection, trauma
Useful if MRI contraindicated

Question 23

When is MRI used to investigate back pain?

Answer 23

• visualise soft tissue
• If suspicious of a new fracture/ microfractures
• shows bony oedema
• *IF RED FLAGS USE MRI FIRST THEN CT**

Question 24

What is a radionuclide bone scan used to investigate in back pain?

Answer 24

• Shows increased bone turnover (e.g. Pagets disease, Ankylosing Spondylitis)
• Shows Tumours and metastases as these have increased cell turnover

Question 25

Why is a PET scan used in back pain investigation?

Answer 25

Increased uptake in areas of high turnover | - closest modality we currently have to imaging areas of pain

Question 26

What are lab tests used for in the context of back pain?

Answer 26

Rule out malignancy and infection

Question 27

What non-pharmacological treatments are used in back pain?

Answer 27

- Explain/educate - reassure most is self-limiting - advice on activity/exercise

Question 28

What simple analgesia is often used in back pain management?

Answer 28

NSAIDs (useful for MSK pain, but unsuitable for many patients) Opioids for breakthrough pain

Question 29

What Injections can provide relief in back pain?

Answer 29

Facet joint injections | Epidural blocks

Question 30

What complementary/alternative therapy is sometimes used in back pain?

Answer 30

``` acupuncture chiropractor osteopath massage PHYSIO ```

Question 31

When should you begin to investigate a patient with back pain?

Answer 31

If no improvement after 4-6 weeks of conservative management

Question 32

When should back pain be referred?

Answer 32

intractable pain serious pathology suspected neurological deficit

Question 33

What are the risk factors for mechanical back pain?

Answer 33

Previous episode of back pain heavy lifting / frequent bending repetitive work exposure to vibration (construction work)

Question 34

How can back pain be prevented?

Answer 34

Education on lifting/turning with heavy objects Mental coping strategies for pain Smoking cessation

Question 35

Other than mechnical back pain, what differentials could be causing a patients back pain?

Answer 35

Root compression due to degenerative disease Sinister causes (Tumour, TB) Compression outside of spine (e.g. endometriosis) No root compression (peripheral neuropathy)

Question 36

What is piriformis syndrome and what nerve does it affect?

Answer 36

Condition where sciatic nerve runs WITHIN piriformis muscle | => when muscle contracts patient experiences sciatic pain

Question 37

Sciatica is generally self-limting. TRUE/FALSE?

Answer 37

TRUE