5Causes 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.)
9Piriformis syndromePain from piriformis muscle – irritation of sciatic nerve passing deep or through itPain on resisted abduction / external rotation of leg
10Causes 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.
13Causes 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
17Red 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
22Imaging 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
23TREATMENTS 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.
26Occupational 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)
27Blocks to returning to work (blue flags!) perceived work loadlow paymanagement attitudespoor supportloss of confidencedepression
28JD’s top tips for back pain. Patient who attends a second time with “simple” back pain- get them to strip to their underwear!
29Top tipsTrue sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.
30Top tipsWith radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)
31Top TipsPhysios are very good at managing the psychological aspects of chronic pain.
32Top 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.