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Evaluation And Management Of Back Pain
1.How Will You Define Pain?
Pain Is An Unpleasant Sensory And Emotional Experience Associated With Actual Or Potential Tissue Damage Or Described In Terms Of Such Damage. [Iasp 1979]
2.What Are The Principle Types Of Pain ?
There Are Two Principle Types Of Pain
Neuropathic Pain
Nociceptive Pain
3.How Will You Differentiate These Two Types Of Pain?
Both The Pain Variety Has Unique Characteristics And Behaviour Pattern Which Helps In Their Differentiation
Nociceptive Pain
A)Generally Of Acute Variety
B)It Is A Physiological Pain
C) It Is The Symptom Of Disease
D) Associated With Actual Or Potential Tissue Damage
E)It Is Proportionate To Clinical Findings And Biological In Nature
F) Manageable
Neuropathic Pain
A)Generally Of Chronic Variety
B) Rather Than Symptom ,It Itself Is The Manifestation Of The Diseased Nerve
C)It Is Considered As Pathological Pain As The Nerve Which Conducts Pain Is Now Getting Diseased Itself
D)Has A Dissociated Relationship With The Tissue Damage
E)It Is Disproportionate To The Clinical Findings And Non Bilogical In Nature
F)Difficult To Manage
There Are Certain Pain Which Has Features Of Both Neuropathic As Well As Nociceptive Variety Which Is Rather Termed As Mixed Pain.
4.How Will You Define Acute Vs Chronic Pain?
American Pain Association Defines Chronic Pain As Any Pain That Continues One Month Beyond The Usual Recovery Period.
Some Have Defined Chronic Pain As Any Pain Beyond 3 Motnhs Is Chronic Pain As Bythat Time The Nerves Itself Gets Diseased.
Anypain Till It Becomes Chronic Is Termed As Acute Pain .
5.What Is Radicular Pain Vs Radiculitis Vs Radiculopathy?
Radiculitis Is An Inflammation Of Nerve Root
Radicular Pain Is The Pain Described Along The Course Of The Nerve Root
Radiculopathy Is The Involvement Of Motor Component Of Nerve Along With Sensory Component. In Short Radicular Syndrome+ Motor Weakness+Loss Of Reflex.
6.How Will You Differentiate Referred Pain From Radiculopathy?
Referred Pain
A)Generally Dullaching Expanding Pain
B)As Far As Back Is Concerned It Doesn’t Go Beyond Knee
C) It Is Better Defined
D)It Is Both Superficial And Deep In Nature
E) Neurologically Normal
Radiculopathy
A)Generally Shooting, Electric Type Of Pain
B)In Back Generally Goes Below The Knee Region
C)Ill Defined
D)Deep
E)May Have Motor With Sensory Involvement
7.What Are The Clinical Symptoms Of Neuropathic Pain?
Symptoms Can Be In The Form Of Shooting Pain, Electric Current Feel, Tingling Numbness,Allodynia, Hyperalgesia,Burning, Stabbing, Pins And Needle Feeling.
8.How Will You Define Low Back Pain?
Any Pain In Between 12 Th Rib And The Gluteal Folds Is Called As Low Back Pain
Ocassionally It May Extend Upto The Knee But Never Beyond It
9.What Are The Commonest Causes Of Acute And Chronic Low Back Pain ?
The Commonest Causes Of Acute Low Back Pain In The Decreasing Order Of Importance
A)Musculoligamentous Strain/ Sprain
B)Acute Prolapse Of Intervertebral Disc
C)Poor Posture
D)Fractures/ Trauma
E)Sacroiliac Dysfunction
F)Infection
G)Other Rare Causes As Ureteric Stone, Pancreatitis,Ruptured Aortic Aneurysm Etc
The Commonest Causes Of Chronic Low Back Pain In The Decreasing Order Of Importance
A)Facet Joint
B)Internal Disc Disruption
C)Sacroiliac Joint Dysfunction
D)Prolapse Intervertebral Disc
E)Chronic Regional Pain Syndrome
F)Osteoporotic Compression Fractires
G)Myofascial Pain Syndromes Including Fibromyalgia
H)Spinal Canal Stenosis
I)Spondylolisthessis
J)Tumor
J)Infection
10.What Is The Key In Making A Proper Diagnosis Of Cause Of Back Pain?
History And Clinical Examination Is The Key In Making A Proper Diagnosis For The Cause Of Back Pain And That Investigations Only Corroborates The Clinical Findings.
11.What Are The Key Points In Making A Diagnosis Of Facet Joint Pain?
The Key Points In Making A Facetal Pain Diagnosis Are As Follows
More Common In Elderly
Back Pain >Leg Pain
Pain On Extension----Pain On Rising From Chair,Standing
Pain On Rotations/Lateral Bending
Rarely Follows Dermatoma;L Pattern
12. What Is The Gold Standard In Diagnosing Facet Pain?
Facet Joint Injection With Local Anaesthetic (Diagnostic Block) Or Median Nerve Branch Block Which Supplies Facet Joint Injection Is The Gold Standard For Diagnosing Facet Pain Origin.
13.How Will A Patient With Internal Disc Disrution Present To The Clinic?
Key Points In Internal Disc Disruption Are
A)More Common In Young Population
B)Back Pain >Leg Pain
C)Pain On Flexion---Pain On Sitting
D)No Nerve Root Related Symptoms Like Radicular Pain, Motor Symptoms
E).Non Dermatomal Distribution Of Pain
F)Axial Variety Of Pain
G) Straight Leg Negative
14. What Investigation Will You Like To Carry Out In Suspected Case Of Internal Disc Disruption?
Mri Remains The Gold Standard For Idd Which May Show Tear In Annulus Fibrosis With Nucleus Pulposus Material Escaping In The Layers Of Annulus Fibrosis
Provocative Discogram---Concordant Pain Experienced On Injecting Dye In The Disc Is The Key To Clinch The Perfect Diagnosis But Cumbersome And Painful To The Patient.
15.What Is The First Clinical Diagnosis Of A Patient Complaining Of Severe Leg Pain Radiating From Back?
The First Clinical Impression Of A Patient Presenting With Sciatica Complaints Is Prolapse Intervertebral Disc But To Make A Perfect Diagnosis One Has To Look For Following Features
A)Leg Pain > Back Pain
B) Generally Elderly Population
C)May Have Initial Past History Of Back Pain Followed By Leg Pain
D)History Of Acute Stressful Episodes In Form Of Lifting Weightetc
E)Shooting / Electrical Current Type Of Pain Going Beyond The Klnee
F)Motor Involvement May Be There
G) Pain Is Dermatomally Distributed
H) Common Involvement Of L 5 And S 1 Region
I)Pain On Flexion / Extension / Lateral Bending On The Side Of Prolapse Often
J) Mild Relief Of Pain With Knee Flexion
J) Straight Leg Raise Test Positive
