5 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.)
9 Piriformis syndromePain from piriformis muscle – irritation of sciatic nerve passing deep or through itPain on resisted abduction / external rotation of leg
10 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.
13 Causes of low back pain 4 Inflammatory – Ankylosing Spondylitis Difficult to diagnose if early stages but:Morning stiffness for > 30 minutesPain that alternates from side to side of lumbar spineSternocostal painReduced chest expansionSchobers test
17 Red Flags Weight loss, fever, night sweats History of malignancy Acute onset in the elderlyNeurological disturbance Bilateral or alternating symptomsSphincter disturbanceImmunosuppressionInfection (current/recent)Claudication or signs of peripheral ischaemiaNocturnal pain
20 Causes of back pain Structural Mechanical Facet joint arthritis Proplapsed intervertebral disc Spondylolysis / Spinal stenosisInflammatorySacroiliitisSpondyloarthropathiesInfectionMetabolicOsteoporotic vertebral collapse Paget's disease OsteomalaciaNeoplasmCa ProstateCa Breast
21 Referred pain Pleuritic pain Upper UTI / renal calculus Abdominal aortic aneurysmUterine pathology (fibroids)Irritable bowel (SI pain)Hip pathology
22 Imaging modalitiesXrays good first line Ix if red flags, osteoporotic fractureBone scan (also good initial Ix if Xray nad and red flags) - mets, infection, pagets, PMRCT Scan bone tumours fractures and spinal stenosisMRI spinal cord, nerve roots, discs, haemorrhageDexa Scan Bone density
23 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.
24 No evidence for: Short wave diathermy TENS Spinal manipulation TractionAcupunctureExercisesSpinal cortisone injections
26 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 workMDT Rehabilitation programs: psychological therapies; CBT; graduated return to work (light duties)
27 Blocks to returning to work (blue flags!) perceived work loadlow paymanagement attitudespoor supportloss of confidencedepression
28 JD’s top tips for back pain. Patient who attends a second time with “simple” back pain- get them to strip to their underwear!
29 Top tipsTrue sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.
30 Top tipsWith radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)
31 Top TipsPhysios are very good at managing the psychological aspects of chronic pain.
32 Top TipsSending 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.