what is sciatica?
back pain radiating down leg
how does sciatica vary?
depends on which nerve affected in referred pain as to how far it travels
what is the recovery from sciatica?
- 60% recovered in 3 months
- 70% recovered in 12 months
- 30% continue to have sciatica for over 1 year
what is non-specific low back pain?
pain not due to any specific or underlying disease that can be found
what is mechanical low back pain?
pain after abnormal stress and strain on vertebral column
what is nerve root pain (sciatica)
pain radiating to the lower limbs with or without neuralgic symptoms
what are the causes of low back pain?
- Mechanical:
- Tumour including myeloma
- Infection
- spondyloarthropathy
- pars interarticularis injury (pars oedema is early sign)
- compression fracture
- visceral- pain from elsewhere in bondy
what are the mechanical causes of lower back pain?
disk degeneration
disk herniation
annular tears
facet joint osteoarthritis
instability
what are annular tears?
rips within disc- allow inner to leak out and cause irritation
what are the indicators for sciatica?
- Unilateral leg pain greater than low back pain
- Pain radiating to foot or toes
- Numbness and paraesthesia in the same distribution
- Straight leg raising test induces more leg pain
- Localised neurology (limited to one nerve root)
what are the conservative treatments for sciatica?
- Analgesia
- Anti-inflammatory drugs
- Manipulation
- Acupuncture
- Massage
- Allow some time to pass
- Bed rest does not result in faster recover (bed rest required if unstable issue!)
- Most patients get better spontaneously
what are the red flags for low back pain and leg pain?
weight loss
fever
night pain
under 19
bowel/bladder dysfunction
saddle anesthesia
profound neurological deficits
what is the protocol for patient with red flag symptoms?
imaging
what is the protocol for a patient with leg and back pain without red flags?
wait 6-12 weeks
what are the risks of waitng too long to treat back pain?
metastases
inflammatory arthropathy
myeloma
tuberculosis of spine
what is the risk of metastases in back pain diagnosis?
- Early diagnostic may not impact on prognosis
- Risk of catastrophic fracture and paralysis
- Onset of symptoms to referral medial 3 months
what is the benefit of early diagnosis of inflammatory arthropathy?
early diagnosis for effective treatment with biologics
investigate under 35 years after 3 months pain
what is the benefit and meantime for diagnosis of myeloma
- Early diagnosis will catch disease at more easily treated stage
Mean delay in diagnosis- IQR 84-306 days
what is the benefit and mean time for diagnosis of tuberculosis of spine?
early diagnosis essential for effective treatment
mean delay in diagnosis- 4-11 months
what is the primary investigation for back pain?
MRI
- Secondary = Radiographs & CT
- Radiographs have negligible value in the assessment of back pain (prefered on young people with spinal deformity)
- CT is an adjunct in a few cases
- Low back pain is non-specific until you investigate
what are the benefits and negatives of radiographs?
cheap
readily available
radiation
overlook most important diseases
what are the methods of pain therapy for back pain?
- Physical therapy
- Analgesia
- Facet injection
- Local & steroid
- Denervation
- Root block
- Epidural injection
- Neurostimulation
how are facet infections given?
- Different approaches:
- Oblique
- Posterior
- 21g needle
- Local anaesthetic
- Steroid injection that will take effect at 1 week
- Inside or around the joint
- Inject the posterior inferior extension of the joint
how is a root block given?
contrast in root sheath
CT guided
