Back Pain and Related Symptoms (e.g., Sciatica) - MCCQE1 Prep Guide

Introduction

Back pain is a common presenting complaint in primary care settings across Canada. As a future Canadian physician preparing for the MCCQE1, understanding the nuances of back pain and related symptoms like sciatica is crucial. This comprehensive guide will help you navigate through the key concepts, Canadian guidelines, and MCCQE1-specific information you need to know.

Epidemiology in the Canadian Context

• Back pain affects approximately 80% of Canadians at some point in their lives
• It is the leading cause of disability in Canada for those under 45 years old
• Annual prevalence of low back pain in Canada: 20-25% of adults
• Sciatica affects 5-10% of patients with low back pain

Anatomy and Pathophysiology

Understanding the anatomy and pathophysiology is crucial for diagnosing and managing back pain effectively.

Key Anatomical Structures

1. Vertebrae
2. Intervertebral discs
3. Spinal cord and nerve roots
4. Muscles and ligaments

Common Causes of Back Pain

Clinical Presentation and Assessment

History Taking

Physical Examination

1. Inspection: Look for spinal alignment, posture, and gait
2. Palpation: Check for tenderness, muscle spasm, and deformities
3. Range of motion: Assess flexion, extension, lateral bending, and rotation
4. Neurological examination: Test sensation, motor strength, and reflexes
5. Special tests:
   • Straight Leg Raise (SLR) test for sciatica
   • Slump test
   • Femoral stretch test

Diagnostic Approach

Laboratory Tests

• Complete Blood Count (CBC)
• Erythrocyte Sedimentation Rate (ESR)
• C-Reactive Protein (CRP)
• HLA-B27 (if suspecting ankylosing spondylitis)

Imaging Studies

1. X-ray: First-line imaging for trauma or suspected bony abnormalities
2. MRI: Gold standard for soft tissue and neurological involvement
3. CT scan: Useful for bony details when MRI is contraindicated
4. Bone scan: To detect occult fractures or metastases

Management

Management of back pain in Canada follows a stepwise approach, emphasizing conservative measures before considering invasive treatments.

Non-pharmacological Approaches

1. Patient education and reassurance
2. Physical therapy and exercise programs
3. Acupuncture (covered by some provincial health plans)
4. Cognitive Behavioral Therapy (CBT)

Pharmacological Management

Invasive Treatments

• Epidural steroid injections
• Surgical interventions (e.g., discectomy, laminectomy)

Sciatica: A Special Consideration

Sciatica is a specific type of back pain that radiates along the sciatic nerve path.

Key Features of Sciatica

• Pain radiating from the lower back to the buttock and down the leg
• May be accompanied by numbness, tingling, or weakness
• Often caused by a herniated disc or spinal stenosis

Management of Sciatica

1. Conservative treatment similar to general back pain
2. Consider gabapentin or pregabalin for neuropathic pain
3. Surgical intervention if conservative measures fail or in cases of severe neurological deficits

Canadian Guidelines for Back Pain Management

The Canadian Chiropractic Guideline Initiative (CCGI) provides evidence-based recommendations for the management of low back pain:

1. Encourage self-management and physical activity
2. Use manual therapy, including spinal manipulation, for short-term pain relief
3. Consider acupuncture for chronic low back pain
4. Use non-pharmacological treatments as first-line therapy
5. Reserve opioids for severe, refractory pain and use with caution

Key Points to Remember for MCCQE1

• 🍁 Understand the Ottawa Low Back Pain Rule for imaging in trauma cases
• 🍁 Be familiar with Canadian epidemiology of back pain and sciatica
• 🍁 Know the red flags suggesting serious underlying conditions
• 🍁 Emphasize conservative management as per Canadian guidelines
• 🍁 Be aware of the limitations on opioid use in Canada
• 🍁 Understand the role of allied health professionals (physiotherapists, chiropractors) in back pain management within the Canadian healthcare system

Sample Question

# Sample Question

A 45-year-old woman presents to her family physician with a 3-week history of low back pain radiating down her left leg to her foot. She denies any trauma or recent lifting. The pain is worse with sitting and improves with walking. Physical examination reveals a positive straight leg raise test on the left at 30 degrees. Which one of the following is the most appropriate next step in management?

- [ ] A. Order an immediate MRI of the lumbar spine
- [ ] B. Prescribe bed rest for 1 week
- [ ] C. Refer for urgent surgical consultation
- [ ] D. Recommend acetaminophen and physical therapy
- [ ] E. Start a course of oral corticosteroids

Explanation

The correct answer is:

• D. Recommend acetaminophen and physical therapy

This patient's presentation is consistent with sciatica, likely due to a herniated disc. The positive straight leg raise test supports this diagnosis. In the absence of red flags (such as severe neurological deficits, cauda equina syndrome, or suspicion of malignancy), the initial management should be conservative.

Canadian guidelines emphasize conservative management as the first-line approach for most cases of back pain and sciatica. This includes:

1. Pain management with over-the-counter medications like acetaminophen or NSAIDs
2. Encouraging physical activity and exercise
3. Physical therapy to improve strength and flexibility

Options A (immediate MRI) and C (urgent surgical consultation) are not appropriate as initial steps in the absence of red flags. Option B (bed rest) is no longer recommended for back pain as it can lead to deconditioning. Option E (oral corticosteroids) is not a first-line treatment for sciatica in Canada and should be reserved for specific cases under specialist guidance.

References

1. Canadian Chiropractic Guideline Initiative. (2018). Clinical Practice Guidelines for the Management of Low Back Pain. Link (opens in a new tab)

2. Choosing Wisely Canada. (2021). Imaging Tests for Lower Back Pain: When you need them and when you don't. Link (opens in a new tab)

3. Toward Optimized Practice (TOP) Low Back Pain Working Group. (2015). Evidence-informed primary care management of low back pain: Clinical practice guideline. Edmonton, AB: Toward Optimized Practice. Link (opens in a new tab)

4. Canadian Medical Association Journal. (2017). Management of low back pain in Canadian emergency departments. CMAJ, 189(45), E1397-E1404. Link (opens in a new tab)

5. Busse, J. W., Craigie, S., Juurlink, D. N., et al. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ, 189(18), E659-E666. Link (opens in a new tab)