Back Pain - Bradford VTS
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Transcript Back Pain - Bradford VTS
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 arthritis
Proplapsed
intervertebral disc
Spondylolysis / Spinal
stenosis
Inflammatory
SacroiliitisSpondyloart
hropathies
Infection
Metabolic
Osteoporotic
vertebral collapse
Paget's disease
Osteomalacia
Neoplasm
Ca Prostate
Ca 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 rest
Paracetamol (+nsaid if insufficient)
Avoid opiates if at all possible
No evidence that co-analgesics better than
paracetamol alone.
Muscle relaxants (diazepam / methocarbamol) small
additional benefit.
No evidence for:
Short wave diathermy
TENS
Spinal manipulation
Traction
Acupuncture
Exercises
Spinal cortisone injections
Occupational issues
Occupational issues
More sick leave : Less chance of recovery
4-12 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 load
low pay
management attitudes
poor support
loss of confidence
depression
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.