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Flashcards in Back Pain Deck (58)
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1

Incidence and impact of Back pain

80% lifetime incidence -- 75% of pts improve within 4wks, 95% within 6wks BUT 70% recurrence - 1.6million chronic sufferers
2nd most common illness after the cold -- biggest reason people see GPs and costs £12.3bn/yr

2

Causes of low back pain

95% -- mechanical low back pain
4% -- Nerve root pain
1% -- Serious spine pathology

3

Yellow flags versus Red flags

Red flags are signs of serious sinister pathology
Yellow flags are psycho-social predictors of poor outcome (A,B,C,D,E,F,W)

4

Yellow flags for low back pain

Attitudes & beliefs about back pain
Behaviours, Compensation issues, Diagnosis and treatment issues, Emotions, Family and Work

5

Red flags for low back pain (5,4,7)

Types of pain: constant or Progressive, nocturnal, thoracic, bony tenderness, insidious onset,
Associated symptoms: weight loss, fever, night sweats, persistent severe restriction of lumbar flexion
History: Trauma, Hx of Ca, Steroid use, IV drug use, HIV or immunosuppression, Structural deformity, age 50yrs,

6

Unhelpful beliefs (2) or behaviours (2) about low back pain

The belief that pain is harmful or severely disabling
Expectation that passive treatment not active participation will help
Fear/avoidance behaviour
Low mood and social withdrawal

7

Serious spinal pathology which causes back pain (6)

Trauma or fractures
Infection (TB, etc)
Malignancy (primary or secondary)
Cauda equina
Inflammatory
Visceral (referred)

8

Detecting serious spinal causes when asking about back pain

Always search for red flags -- patient may not volunteer them -- may not have thought to comment on weight loss etc

9

Causes of Nerve Root pain

Herniated discs - 90% - (protrusion, extrusion or sequestration)
Canal or foraminal stenosis - can effect the exiting or 'traversing' nerve root (one vertebrae below)
Spondylolithesis

10

Disc Protrusion

Focal or symmetric protrusion of the nucleus pulposis beyond the end-plate but the annulus is still intact

11

Disc Extrusion

Disc/nucleus extends beyond the confines of the annulus

12

Disc Sequestration

Fragmentation of the disc where there is no continuity with the original disc

13

Presentation of Herniated discs

Unilateral (can be bilateral) - leg pain>back pain --> dermatomal pattern -- may also have paraesthesia or changes in power, sensation or reflexes (single nerve root)
Lumbar flexion is restricted
Nerve irritation/radiculopathy signs

14

Nerve irritation/radiculopathy signs

Limitation of the straight leg raise with reproduction of leg pain (not back pain) -- coughing/sneezing worsens pain
pain may be sharp or shooting
Crossed straight leg raise -- if lifting the unaffected leg causes pain in the affected leg this is very specific for sciatic radiculopathy

15

Nerve roots most commonly affected by herniated discs

L4-5 and L5-S1 -- this will effect L4, L5 and S1 (the sciatic nerve)

16

L2 nerve Root

Dermatome -- Groin
Myotome -- Hip flexors and adductors
Reflex -- none

17

L3 nerve Root

Dermatome -- Lateral/anterior thigh
Myotome -- Quads (hip addiction, knee extension)
Reflex -- Knee jerk

18

L4 nerve Root

Dermatome -- Medial lower leg to med malleolus
Myotome -- dorsiflexion of the ankle/foot, foot inversion
Reflex -- Knee jerk

19

L5 nerve Root

Dermatome -- Dorsum of the foot and big toe
Myotome -- Foot eversion & extensor hallus longus
Reflex -- none

20

S1 nerve Root

Dermatome -- Lateral border of the foot and sole
Myotome -- Knee flexion, plantar flexion of the foot, foot eversion
Reflex -- Ankle jerk

21

Treatment of nerve root pain

90% will improve with 6 weeks -- educate, reassure and advise -- 95% resolve within 12wks -- After 12wks consider physiotherapy, medication or surgery/injections (if getting worse) -only after MRI

22

Interventions for worsening nerve root pain

Injections -- nerve root block for back pain & epidural for back and leg pain -- evidence is conflicting
Surgery -- Microdiscectomy, discectomy or fusion of vertebrae -- little significant evidence supporting surgery over non-operative management

23

Criteria for nerve root surgery

Radiculopathy and severe pain unrelieved by conservative management lasting >6wks with progressive neurological deficit -- must be imaging showing disc herniation with correlates with examination findings

24

Spondylolithesis - what is it, how can it be graded and what types are there?

Anterior displacement of the vertebrae or vertebral column in relation to the vertebrae below -- most commonly L5 on S1
Can be graded Meyerding or Wiltse
Can be traumatic, Isthmic or Degenerative
Posterior displacement is retrolithesis

25

Grading Spondylolithesis - Meyerding

Based on percentage anterior slippage:
Grade 1 -- up to 25%, Grade 2 -- 25-50%,
Grade 3 -- 50-75%, Grade 4 -- 76-100%,
Grade 5 -- Below the anterior border of the lower vertebrae

26

Grading Spondylolithesis - Wiltse

Based on cause:
Type 1 -- Dysplastic, Type 2 -- Isthmic,
Type 3 -- Degerative, Type 4 -- Traumatic,
Type 5 -- Pathological, Type 6 -- Post-surgical
Did I do that pathological person?

27

Isthmic spondylolisthesis (Wiltse type 2)

Developmental -- most common form (~5% of pop) but cause unknown
Lesion of per interarticularitis of L4 or L5 - can be unilateral or bilateral
Due to abnormal development of the neural arch or a genetically induced weakness

28

Common presentations of Isthmic spondylolisthesis

Adolescents/young adults as due to fatigue fracture (repetitive stress) rather than acute trauma --> weightlifting, gymnastics, football etc
Usually occurs 6-16yrs but may present years later

29

Signs of Isthmic spondylolisthesis

Gradual onset of general low back ache with repetitive movements, morning stiffness and night pain after activity
May have unilateral lumbar, buttock or leg pain if nervous entrapment
Aggravated by prolonged standing, walking or running

30

Degenerative spondylolisthesis (Wiltse type 3)

5-6x more common in women -- not associated with a pars defect -- result of facet joint degeneration (possibly spinal structure or hormonal ligament weakness)
Most common at L4/5