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Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS.

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Presentation on theme: "Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS."— Presentation transcript:

1 Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS


3 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

4 Causes of back pain 1

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.)

6 Structures that cause nerve root compression

7 L4/L5/S1 Radiculopathy

8 Straight Leg Raising

9 Piriformis syndrome Pain from piriformis muscle – irritation of sciatic nerve passing deep or through it Pain 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.

11 Cauda Equina syndrome (spinal canal compression)

12 Spinal Stenosis

13 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

14 Schobers Test

15 Fabere test

16 Pelvic Compression Test

17 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

18 Yellow flags 1

19 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

20 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

21 Referred pain Pleuritic pain Upper UTI / renal calculus Abdominal aortic aneurysm Uterine pathology (fibroids) Irritable bowel (SI pain) Hip pathology

22 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

23 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.

24 No evidence for: Short wave diathermy TENS Spinal manipulation Traction Acupuncture Exercises Spinal cortisone injections

25 Occupational issues

26 More sick leave : Less chance of recovery 4-12 w - 40% chance of still being off at 1 year. Dont need to be pain free to return to work MDT Rehabilitation programs: psychological therapies; CBT; graduated return to work (light duties)

27 Blocks to returning to work (blue flags!) perceived work load low pay management attitudes poor support loss of confidence depression

28 JDs top tips for back pain. Patient who attends a second time with simple back pain- get them to strip to their underwear!

29 Top tips True sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.

30 Top tips With radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)

31 Top Tips Physios are very good at managing the psychological aspects of chronic pain.

32 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.

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