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Q1: Approach & triage (2 min)
A 40-year-old presents with acute low back pain. Take us through your structured approach. Cover: the principle that over 90 percent of low back pain is non-specific and self-limiting (recovers within six weeks); the triage into non-specific (mechanical), radicular (sciatica), and serious specific pathology; and why the central skill is the systematic search for red flags rather than reflexive imaging.
Q2: Red flags & cauda equina (2 min)
What are the red flags in low back pain, and which is the true emergency? Cover: cauda equina (saddle anaesthesia, urinary/faecal retention or incontinence, bilateral neurology, progressive weakness, reduced anal tone) = surgical emergency needing urgent MRI and decompression within 24 to 48 hours; trauma, age over 50, corticosteroids (fracture); fever, weight loss, night sweats, immunosuppression, IV drug use (infection); history of cancer (metastasis); insidious inflammatory pain in the young better with exercise (axial spondyloarthritis).
Q3: Examination & nerve root localisation (2 min)
How do you examine the back and localise a radiculopathy? Cover: inspection (posture, gait, step deformity), palpation, range of motion, modified Schober test (inflammatory restriction); the root map — L4 (knee extension, patellar reflex), L5 (great toe dorsiflexion, no reliable reflex), S1 (plantarflexion, Achilles reflex); straight leg raise (leg pain below knee at under 70 degrees = L5/S1 root irritation; crossed SLR more specific); and the cauda equina screen (saddle sensation, anal tone, bladder scan for retention).
Q4: Investigations — when to image (2 min)
When would you image low back pain, and with what? Cover: do NOT routinely image non-specific acute pain (under six weeks) — incidental disc bulges and degeneration are common in pain-free adults and imaging drives overdiagnosis, opioids and unnecessary surgery. MRI is first-line for red flags (cauda equina, infection, malignancy), progressive neurological deficit, or persistent radiculopathy over six weeks. Bloods (FBC, CRP, ESR) if infection/malignancy suspected; HLA-B27 and MRI of SI joints for suspected axial spondyloarthritis.
Q5: Management of non-specific pain (2 min)
How do you manage acute non-specific low back pain? Cover: education, reassurance, stay active, return to work; simple analgesia (paracetamol or NSAIDs; avoid opioids); heat; short-term manual therapy/spinal manipulation; avoid bed rest, routine imaging, opioids and injections. For persistent pain (over six weeks): supervised exercise + cognitive behavioural therapy; multidisciplinary biopsychosocial rehabilitation for chronic disabling pain. For sciatica: conservative first; surgery for severe persistent radiculopathy or progressive motor deficit. Mention the PACE trial finding that paracetamol was no better than placebo for acute pain.
Q6: Prognosis & chronicity (1 min)
What determines outcome and what predicts chronicity? Cover: about 90 percent recover within six weeks, but recurrence is common. Yellow flags predict chronicity: high baseline disability, psychological distress (depression, anxiety), fear-avoidance beliefs and catastrophising, low job satisfaction, heavy manual work, widespread pain, and prior prolonged episodes. Addressing these early prevents the transition to chronic disabling pain.