51 Questions
Match the following imaging techniques with their ability to detect specific spinal conditions:
X-rays = Not recommended for most patients with low back pain MRI = More sensitive than plain films for detecting spinal infections, cancers, herniated disks, and spinal stenosis CT = More sensitive than plain films for detecting spinal infections, cancers, herniated disks, and spinal stenosis Plain films = Less sensitive than MRI and CT for detecting spinal infections, cancers, herniated disks, and spinal stenosis
Match the following management approaches with their recommended duration for bed rest:
Mechanical low back pain = Bed rest not generally recommended unless pain is severe enough to preclude normal activities; if needed, limited to 2 to 3 days Non-mechanical causes of low back pain = Bed rest not generally recommended unless pain is severe enough to preclude normal activities; if needed, limited to 2 to 3 days Acute phase of low back pain = Bed rest not generally recommended unless pain is severe enough to preclude normal activities; if needed, limited to 2 to 3 days Chronic low back pain = Bed rest not generally recommended unless pain is severe enough to preclude normal activities; if needed, limited to 2 to 3 days
Match the following pharmacological treatments with their cautions or considerations:
NSAIDs = Cautious use in patients with a history of gastritis, asthma, hypertension, chronic renal failure, or CHF Muscle relaxants = Consideration based on pain severity Opioid therapy = Consideration for short course if pain is severe Traction and analgesic injection = Usually not helpful in the acute stage of low back pain
Match the following surgical treatment indications with their associated low back pain conditions:
Cauda equina syndrome and worsening neurologic deficits = Indicative of potential benefit from surgery if conservative care fails Herniated disks and spinal stenosis = Indicative of potential benefit from surgery if conservative care fails Disabling symptoms without response to conservative care = Indicative of potential benefit from surgery if conservative care fails Fractures and infection = Not specifically mentioned as indicative of potential benefit from surgery if conservative care fails
Match the following urgent/emergency referrals with their corresponding low back pain conditions:
Cauda equina and severe radiculopathy = Urgent/Emergency referrals Fractures and recalcitrant spinal canal stenosis = Other referrals Neoplasia or infection and undiagnosed back pain = Other referrals Continuing pain of 3 months’ duration without a clearly definable cause and erectile dysfunction = Other referrals
Match the following prevention and education tips with their corresponding back care advice:
Losing weight = Preventive measure for strain on the lower back Posture while sitting, standing, and lying down = Tips for maintaining good posture to support the back Lifting and carrying techniques = Guidelines for preventing back injury while handling objects Exercise recommendations = Advice for improving core muscle strength that supports the back
Match the following back pain characteristics with their corresponding types:
Can feel better or worse based on position, typically worsens with movement = Mechanical back pain Age at onset of back pain: 3 months = Inflammation-related back pain Characterized by radicular pain (pain that radiates into the lower extremity directly along the course of a spinal nerve root) = Root nerve compression Most cases occur in patients older than 50 years = Malignancy-related back pain
Match the following back pain examination techniques with their descriptions:
Palpation of spine processes, para-vertebral muscles, and sacroiliac joint = Physical examination for back pain Range of motion testing in flexion, extension, lateral bending, and rotation = Physical examination for back pain Special tests like the straight-leg raise and Patrick’s test (FABER) = Physical examination for back pain Inspection of the back for scoliosis, lordosis, swelling, scars, and muscle wasting = Physical examination for back pain
Match the following back pain cases with their corresponding patient descriptions:
38-year-old man with acute low back pain after lifting boxes = Case 1 20-year-old man with chronic low back pain and stiffness = Case 2 9-year-old male patient with severe lower back pain and radicular right leg pain = Case 3 78-year-old man with new onset low back pain and metastatic prostate cancer = Case 4
Match the following symptoms with their corresponding indications for investigations:
Progressive neurological findings = Indications for investigations Constitutional symptoms = Indications for investigations History of traumatic onset = Indications for investigations History of malignancy = Indications for investigations
Match the following risk factors with their corresponding investigations:
Infectious risk such as injection drug use = Indications for investigations Immunosuppression = Indications for investigations Indwelling urinary catheter = Indications for investigations Prolonged steroid use = Indications for investigations
Match the following durations of back pain with their corresponding time frames:
Acute pain = Less than 6 weeks Subacute pain = 6 – 12 weeks Chronic pain = More than 12 weeks Constant pain = Uninterrupted
Match the following risk factors with their association to back pain:
Smoking = Risk factor for back pain Obesity = Risk factor for back pain Older age = Risk factor for back pain Physically strenuous work = Risk factor for back pain
Match the following components of history taking with their corresponding categories:
Personal Data = Category of history taking SOCRATES = Category of history taking Red Flags = Category of history taking PMH Hx = Category of history taking
Match the following psychological factors with their association to back pain:
Somatization disorder = Psychological factor associated with back pain Anxiety = Psychological factor associated with back pain Depression = Psychological factor associated with back pain PTSD = Psychological factor associated with back pain
Match the following elements of SOCRATES with their descriptions:
Site = Element of SOCRATES Onset = Element of SOCRATES Exacerbating = Element of SOCRATES Radiation = Element of SOCRATES
Match the following past medical history factors with their relevance to back pain:
Trauma = Relevance to back pain in past medical history Cancer = Relevance to back pain in past medical history Osteoporosis = Relevance to back pain in past medical history Diabetes mellitus = Relevance to back pain in past medical history
Match the following medication categories with their potential impact on back pain:
Psychotic medications = Impact on back pain Steroids = Impact on back pain NSAIDs = Impact on back pain Antibiotics = Impact on back pain
Match the following family and social factors with their relevance to back pain:
Inherited disease = Relevance to back pain in family and social factors Smoking habits = Relevance to back pain in family and social factors Alcohol consumption = Relevance to back pain in family and social factors Dietary habits = Relevance to back pain in family and social factors
Match the following types of back pain with their corresponding locations:
Lumbosacral area = Location of common type of back pain Thoracic spine region = Location of common type of back pain Cervical spine region = Location of common type of back pain Sacral region = Location of common type of back pain
Match the following types of work with their association to risk of developing back pain:
Physically strenuous work = + Risk of developing back pain Sedentary work = - Risk of developing back pain Manual labor work = + Risk of developing back pain Office-based work = - Risk of developing back pain
Physical examination for back pain includes range of motion testing in flexion, extension, lateral bending, and rotation.
True
Mechanical back pain typically improves with movement and worsens with rest.
False
Inflammation-related back pain worsens with rest and improves with activity.
True
Root nerve compression can be due to herniated discs or other conditions impinging on nerve roots.
True
Malignancy-related back pain is more common in patients younger than 50 years old.
False
A 20-year-old man with chronic low back pain and stiffness is likely to have malignancy-related back pain.
False
Back pain patients with a history of malignancy should undergo investigations.
True
Blood tests are necessary for all patients with back pain.
False
Patients who may require long-term NSAIDs may require baseline renal and liver function tests.
True
Patients with back pain and age ≥50 years are not indicated for investigations.
False
Back pain is one of the most common medical problems worldwide, affecting up to 84 percent of adults at some point in their lives.
True
Chronic pain is defined as lasting more than 6 weeks.
False
Red flag symptoms help identify when to refer a patient with back pain to a specialist.
True
Psychological factors such as somatization disorder, anxiety, and depression are not considered risk factors for back pain.
False
The SOCRATES mnemonic is used to gather information about the site, onset, timing, character, exacerbating factors, radiation, and severity of the back pain.
True
Occupation and smoking are considered risk factors for developing back pain.
True
The acronym PMH stands for Past Medical History and is an important part of assessing a patient with back pain.
True
History taking for patients with back pain includes gathering information about personal data, SOCRATES, red flags, PMH, past surgical history, medications, and family, social, and systemic review.
True
Subacute pain is defined as lasting between 6 to 12 weeks.
True
The acronym AAFP stands for American Academy of Family Physicians, which has identified smoking, obesity, older age, female gender, physically strenuous work, and sedentary work as risk factors for developing back pain.
True
X-rays are recommended for most patients with low back pain, regardless of the duration of their symptoms.
False
Both MRI and CT scans are more sensitive than plain films for detecting spinal infections, cancers, herniated disks, and spinal stenosis.
True
Bed rest is generally recommended for all patients with low back pain, regardless of the severity of their symptoms.
False
Longer periods of bed rest can result in deconditioning.
True
Traction and analgesic injection are usually helpful in the acute stage of low back pain.
False
NSAIDs should be used cautiously in patients with a history of gastritis, asthma, hypertension, chronic renal failure, or CHF.
True
Surgical treatment may be beneficial for patients with cauda equina syndrome, worsening neurologic deficits, herniated disks, and spinal stenosis who do not respond to conservative care.
True
Physical therapy or epidural steroid injections benefit all patients with low back pain.
False
Urgent or emergency referrals are indicated for patients with cauda equina, severe radiculopathy, and fractures.
True
Losing weight and maintaining good posture are important preventive measures for low back pain.
True
Study Notes
-
One More Thing: Idea, Concern, Expectation and Emotional/Functional impact on individuals
-
Physical examination for back pain includes:
- Palpation of spine processes, para-vertebral muscles, and sacroiliac joint
- Inspection of the back for scoliosis, lordosis, swelling, scars, and muscle wasting
- Range of motion testing in flexion, extension, lateral bending, and rotation
- Special tests like the straight-leg raise and Patrick’s test (FABER)
-
Mechanical back pain:
- Can feel better or worse based on position, typically worsens with movement
- May develop suddenly or gradually, often occurs for no apparent reason
- Can sometimes be due to poor posture or lifting something awkwardly
- May be the result of a minor injury or no apparent cause
-
Inflammation-related back pain:
- Age at onset of back pain: 3 months
- Night pain and early morning stiffness lasting more than one hour
- Insidious onset
- Tenderness/inflammation over the joint
- Worsens with rest and improves with activity
-
Root nerve compression:
- Characterized by radicular pain (pain that radiates into the lower extremity directly along the course of a spinal nerve root)
- Can be due to herniated discs or other conditions impinging on nerve roots
-
Malignancy-related back pain:
- Most cases occur in patients older than 50 years
- More common than primary tumors of the spine
- Thoracic spine metastatic lesions are more common than lumbar
- Patients usually have constitutional symptoms such as fever, weight loss, loss of appetite, and nausea/vomiting
-
Different cases:
- Case 1: 38-year-old man with acute low back pain after lifting boxes
- Case 2: 20-year-old man with chronic low back pain and stiffness
- Case 3: 9-year-old male patient with severe lower back pain and radicular right leg pain
- Case 4: 78-year-old man with new onset low back pain and metastatic prostate cancer
-
Indications for investigations:
- Progressive neurological findings
- Constitutional symptoms
- History of traumatic onset
- History of malignancy
- Age ≥50 years
- Infectious risk such as injection drug use
- Immunosuppression
- Indwelling urinary catheter
- Prolonged steroid use
- Skin or urinary tract infection
- Osteoporosis
- Blood tests not necessary for most patients with back pain, but CBC, UA, calcium, phosphorus, (ESR), and alkaline phosphatase may be considered in some cases.
- Patients who may require long-term NSAIDs may require baseline renal and liver function tests.
-
One More Thing: Idea, Concern, Expectation and Emotional/Functional impact on individuals
-
Physical examination for back pain includes:
- Palpation of spine processes, para-vertebral muscles, and sacroiliac joint
- Inspection of the back for scoliosis, lordosis, swelling, scars, and muscle wasting
- Range of motion testing in flexion, extension, lateral bending, and rotation
- Special tests like the straight-leg raise and Patrick’s test (FABER)
-
Mechanical back pain:
- Can feel better or worse based on position, typically worsens with movement
- May develop suddenly or gradually, often occurs for no apparent reason
- Can sometimes be due to poor posture or lifting something awkwardly
- May be the result of a minor injury or no apparent cause
-
Inflammation-related back pain:
- Age at onset of back pain: 3 months
- Night pain and early morning stiffness lasting more than one hour
- Insidious onset
- Tenderness/inflammation over the joint
- Worsens with rest and improves with activity
-
Root nerve compression:
- Characterized by radicular pain (pain that radiates into the lower extremity directly along the course of a spinal nerve root)
- Can be due to herniated discs or other conditions impinging on nerve roots
-
Malignancy-related back pain:
- Most cases occur in patients older than 50 years
- More common than primary tumors of the spine
- Thoracic spine metastatic lesions are more common than lumbar
- Patients usually have constitutional symptoms such as fever, weight loss, loss of appetite, and nausea/vomiting
-
Different cases:
- Case 1: 38-year-old man with acute low back pain after lifting boxes
- Case 2: 20-year-old man with chronic low back pain and stiffness
- Case 3: 9-year-old male patient with severe lower back pain and radicular right leg pain
- Case 4: 78-year-old man with new onset low back pain and metastatic prostate cancer
-
Indications for investigations:
- Progressive neurological findings
- Constitutional symptoms
- History of traumatic onset
- History of malignancy
- Age ≥50 years
- Infectious risk such as injection drug use
- Immunosuppression
- Indwelling urinary catheter
- Prolonged steroid use
- Skin or urinary tract infection
- Osteoporosis
- Blood tests not necessary for most patients with back pain, but CBC, UA, calcium, phosphorus, (ESR), and alkaline phosphatase may be considered in some cases.
- Patients who may require long-term NSAIDs may require baseline renal and liver function tests.
Learn about approaching patients with back pain in a primary care setting. Understand the common causes, differentiate between acute and chronic pain, recognize red flag symptoms, and formulate differential diagnoses for mechanical low back pain.
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