Back Pain
32
Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS
description
Back Pain. Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS. Causes of back pain 1. Mechanical - Muscles and ligaments Local tenderness, muscle spasm, loss of lumbar lordosis, percussion tenderness over spinous process NO MOTOR/SENSORY/REFLEXIC LOSS. - PowerPoint PPT Presentation
Transcript of Back Pain
Back Pain
Examination, assessment, red flags,
Good Back Guide.
Jon Dixon, Bradford VTS
Causes of back pain 1
Mechanical - Muscles and ligaments
Local tenderness, muscle spasm, loss of lumbar lordosis, percussion tenderness over spinous process
NO MOTOR/SENSORY/REFLEXIC LOSS
Causes of back pain 1
Causes of low back pain 2
Radicular low back pain Herniated intervertebral disc commonest cause
but can be foraminal stenosis sec. OA / tumours / infection (rare)
TOP TIP not all pain referred down leg is sciatica (facet joint disease / hip / SIJ / piriformis syndrome etc.)
Structures that cause nerve root compression
L4/L5/S1 Radiculopathy
Straight Leg Raising
Piriformis syndrome
Pain from piriformis muscle – irritation of sciatic nerve passing deep or through it
Pain on resisted abduction / external rotation of leg
Causes of low back pain 3
Lumbar Spinal Stenosis Subtle presentation. Bilateral radicular signs should alert to
possibility. Pain on walking- worse on flat –(eases if
hunched over – shopping trolley sign!) Can be mistaken for Claudication. Admit if progressive / or else CT scan.
Cauda Equina syndrome (spinal canal compression)
Spinal Stenosis
Causes of low back pain 4
Inflammatory – Ankylosing Spondylitis
Difficult to diagnose if early stages but: Morning stiffness for > 30 minutes Pain that alternates from side to side of lumbar spine Sternocostal pain Reduced chest expansion
Schobers test
Schobers Test
Fabere test
Pelvic Compression Test
Red Flags
Weight loss, fever, night sweats History of malignancy Acute onset in the elderly Neurological disturbance Bilateral or alternating
symptoms Sphincter disturbance Immunosuppression Infection (current/recent) Claudication or signs of peripheral ischaemia Nocturnal pain
Yellow flags 1
Yellow Flags 2
Factors prolonging back pain Internal factors-Opioid dependency “External controller” patient-type; learned
helplessness; factitious disorder Mental health- depression or anxiety Interpersonal factors "Sick role“ Stressors in relationships Environmental / societal factors- Disability
payments / Litigation / Malingering
Causes of back pain
Structural Mechanical
Facet joint arthritisProplapsed intervertebral discSpondylolysis / Spinal stenosis
Inflammatory SacroiliitisSpondyloart
hropathies
Infection Metabolic Osteoporotic
vertebral collapsePaget's diseaseOsteomalacia
NeoplasmCa ProstateCa Breast
Referred pain
•Pleuritic pain
•Upper UTI / renal calculus
•Abdominal aortic aneurysm
•Uterine pathology (fibroids)
•Irritable bowel (SI pain)
•Hip pathology
Imaging modalities
Xrays good first line Ix if red flags, osteoporotic fracture
Bone scan (also good initial Ix if Xray nad and red flags) - mets, infection, pagets, PMR
CT Scan bone tumours fractures and spinal stenosis
MRI spinal cord, nerve roots, discs, haemorrhage
Dexa Scan Bone density
TREATMENTS Simple Back Pain
(over 95% of cases)Aim: to relieve symptoms and mobilise early.
Avoid Bed restParacetamol (+nsaid if insufficient)Avoid opiates if at all possibleNo evidence that co-analgesics better than
paracetamol alone.Muscle relaxants (diazepam / methocarbamol) small
additional benefit.
No evidence for:
Short wave diathermyTENSSpinal manipulationTractionAcupunctureExercisesSpinal cortisone injections
Occupational issues
Occupational issues
More sick leave : Less chance of recovery4-12 w - 40% chance of still being off at 1
year.Don’t need to be pain free to return to
work MDT Rehabilitation programs:
psychological therapies; CBT; graduated return to work (light duties)
Blocks to returning to work (blue flags!)
perceived work loadlow paymanagement attitudespoor supportloss of confidencedepression
JD’s top tips for back pain.
Patient who attends a second time with “simple” back pain- get them to strip to their underwear!
Top tips
True sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.
Top tips
With radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)
Top Tips
Physios are very good at managing the psychological aspects of chronic pain.
Top Tips
Sending someone to casualty is pointless but can have a very useful ‘placebo’ effect in showing the patient how impressed you are with his or her pain.
