Back pain – a comprehensive guide

Lawrence Pike

James Street Family Practice

Introduction First, we will discuss the formal

medical model: definition, incidence, aetiology, diagnosis, and treatment.

Secondly we will look at the recommendations of the RCGP on Acute Back Pain

Introduction Back pain is one of the most

common ailments of mankind. An estimated 80 percent of people will experience back pain at some point in their lives, and slightly more men suffer from it than women

Potent cause of absence from work

Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic

Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis

Degenerative Osteoarthritis Spondylosis

Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis

Neoplastic Primary Secondary

Prostate Lung Renal Breast Thyroid

Referred Pain Gynaecological Renal Other abdominal

Infection

TB Osteomyelitis Herpes Zoster

Psychological

Depression Malingering

Metabolic

Osteoporosis Paget’s Osteomalacia

History

Sometimes a clear cause but often not

In a young, fit person then usually: muscle or ligament strain facet joint problem prolapsed disc

Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped

by rest

Facet Joint

Sudden backache with a simple movement “I was just picking up a coin off the floor”

Often flexion with rotation May have heard a click

Prolapsed Disc

Shooting pain Pain radiating down the leg below

the knee Aggravated by coughing/sneezing Usually sudden onset and often no

trauma

Red Flags in the History

Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight

loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

Examination

Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes

L4/5 Prolapse

Straight Leg Raising reduced Ankle Jerk present Weakness

Big Toe Foot Dorsiflexion

Sensory Loss Medial foot

L5/S1 Prolapse

Straight leg raising reduced Ankle jerk absent Weakness

Plantar flexion Foot eversion

Sensory Loss Lateral foot

Investigations

For simple backache, age 20-50 <4 weeks duration,no red flags - no x-rays necessary. Patients expect one.

X-ray: recent significant trauma recent mild trauma over 50 prolonged steroid use osteoporosis age over 70

Investigations

Plain x-ray with FBC and ESR to rule out tumour, infection if red flags suggest likely

If red flags present and plain x-ray normal then bone scan, CT or MRI may still be indicated

RCGP Guidelines

Acute Low Back Pain

Clinical Guidelines for the Management of Acute Low Back Pain

First published 1999 Updated yearly Evidence based

Management

RCGP Guidelines recommends triage into 3 groups

1/ simple backache / low back pain 2/ nerve root pain 3/ possible serious spinal

pathology

Simple Backache

Presents 20-55 years Pain in lumbosacral area, buttocks

and thighs “mechanical” pain patient well includes muscle or ligament strain

and facet joint problems

Nerve Root Pain

Unilateral leg pain worse than low back pain

Radiates to foot or toes Numbness and paraesthesia in

same distribution SLR reproduces leg pain Localised neurological signs -

reflexes and power

Possible Serious Spinal Pathology Symptoms of systemic illness -

weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

Cauda Equina Syndrome

Sphincter disturbance Gait disturbance or widespread

motor weakness involving more than on nerve root or progressive motor weakness in the legs

Saddle anaesthesia of anus, perineum or genitals

Needs emergency referral

Red Flags (again)

Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight

loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

Yellow Flags

RCGP refers to Psychosocial problems “Yellow Flags” as they may predict likelihood of Chronicity

May be more important than the physical factors

Lets look at these in more detail

Psychological Risks

Attitudes and Beliefs Distress and Depression Excessive adoption of Sick Role

Social Factors

Family Work

Physical demands of job Job satisfaction Poor health record at work Other factors leading to time off -

medico-legal proceedings, marital strife and financial problems

Psychological Management Encouraging positive attitudes

towards recovery Adequate pain relief and continue

work Reassurance Encourage to keep active, consider

manipulation Back problems become less

common after 50-60

Drug Treatment

Prescribe analgesics at regular intervals, not prn.

Start with paracetamol If inadequate add NSAIDs

(Ibuprofen or Diclofenac) Then try Co-proxamol or Co-

dydramol Finally consider muscle relaxant

Avoidance of Bed Rest

Bed rest has not been shown to be effective in trials of simple backache or nerve root pain

Strong evidence that bed rest leads to debilitation, disability and difficult rehabiliation

Evidence in favour of activity is strong and unequivocal

What to tell the patient

Increase physical activity progressively over a few days or weeks

Stay as active as possible and continue normal daily activities

Stay at work or return to work as soon as possible as beneficial

Who to Refer

Nerve root pain not resolving after 4 weeks (Orthopaedics)

One or more red flags leads to credible evidence of serious pathology

Cauda equina syndrome Can have manipulation as long as

no progressive neurology

Manipulation

Strong evidence that manipulation provides better short-term improvement in pain and activity and higher patient satisfaction

Moderate evidence that risks are very low in trained hands

Back Exercises

Strong evidence that back exercises do not produce any significant improvement in acute back pain

Moderate evidence that exercise programmes can improve pain and function in chronic low back pain

Other Therapies

Inconclusive TENS Shoe insoles or lifts Local injections Back schools

No evidence corsets or supports acupuncture

Other Therapies

Evidence of no effect Traction Physical agents (ultrasound, heat,

ice, diathermy, massage) Evidence against

Narcotics or Benzodiazepines beyond 2 weeks

Plaster jackets Steroids

Summary

Common problem Carry out diagnostic triage Adequate pain relief and early

mobility - resolving < 4 weeks Give positive messages to patient Remember yellow and red flags

Patients perspective

What has happened Why has it happened? Why me?

Why now? What would happen if I did

nothing? What should I do about it? What can you do about it? How can I stop it happening again?