Lower Back Lower Back PainPain

DefinitionsDefinitions• Most backache is ‘mechanical low back pain’

o Symptoms cannot be ascribed to a pathology (infection, tumour, osteoporosis, fracture, radicular syndrome)

• Radicular – nerve root pain• Acute - <6 weeks, sub-acute – 6-12 weeks,

chronic > 12 weeks• Recurrent – New episode after pain free for 6

months

• Affects 80-90% men and women between 30 and 50.

PresentationPresentationHistory Red Flags

• Consider occupation, hobbies or sport

• PMH:o Steroid predisposes to

osteoperosiso History of

malignancy/myeolma

• Patients management

• Recent Violent Trauma• Minor trauma with

osteoperosis• <20 or >50• Hx – Cancer, drug abuse,

HIV, Immunosuppression, corticosteroids

• Constitutional symptoms• Recent bacterial infection• Pain:

o Worse supine, night, thoracic, constant, non-mechanical, unchanged despite treatment

o Morning stiffnesso Saddle anaesthesia or bladder/bowel

change

ExaminationExaminationBasics Red Flag

• Undressed, revealing spine, standing

• Inspection, palpation, function and brief neurologyo More detailed if red flags

• Passive SLRo For nerve root paino Sensitive (90%)o Not specific (20%)

• Structural Deformity• Severe/progressive

deficit• Laxity of anal sphincter• Perianal/perineal sensory

loss• Major Motor Weakness• Cauda Equina

o Bladder dysfunctiono Sphincter disturbanceo Saddle anaesthesiao Lower limb weaknesso Gait disturbance

Differential DiagnosisDifferential Diagnosis• Peripheral Arterial

Diseaseo Pain on walking, relieved by

resto Absent or weak pulseso Include smoking and other

vascular disease

• Infectiono Never forget TB

(osteomyelitis)o HIV predisposes infectionso Pyelonephritis

• Dissecting aortic aneurysmo Pain in back radiating through

to front

• Facet Jointo Acute or chronico Worse morning/standingo Pain over facets – worse on

extension

• Spinal Stenosiso Gradual onseto Unilateral/bilateral leg pain,

numbness worse on walkingo Resolves on sitting/leaning

forwards, crouching downo Diagnose with MRI

• Ankylosing Spondylitiso Young man with lower back pain

and stiffnesso Improves with activityo Peripheral arthritis

InvestigationsInvestigations• If simple low back pain no investigation required• Plain XR

o 120 CXRs, rarely affects management. Should not be used routinelyo Fracture suspectedo Metastatic carcinoma (prostate = sclerotic), (lung, thyroid, kidney = osteolytic),

(breast = both)o Collapse in osteoperosiso Paget’s disease

• CT Scano Best for spondylolisthesis and stress fractures

• MRIo Good picture of soft tissues, will show nerve compressiono Displays disc lesions best

• Bloodso FBC, ESR, CRP – cancer, infection, inflammationo LFTS - ALP in metastatic disease and pagetso PSA – Prostate carcinomao Urine hydroxyproline – Increased in Pagets

ManagementManagement• Low Back Pain

o Information, reassurance and advice – NOT BED REST, Stay Active!

o Regular pain reliefo Referral

• Consider physical treatments, manipulation if not resuming normal activities after a week or two.

• MDT approaches – CBT and ‘back schools’

• Red Flago Urgent refrral e.g. Cauda

Equina to neuro/spinal surgeon

• Chronic Pain, psychosocial factors and yellow flagso Belief that activity is harmfulo Sickness behaviouro Social withdrawalo Emotional problemso Problems at worko Claims, compensation etc.o Overprotective familyo Inappropriate expectations of

Rx (including low)

• Try and challenge behaviours

Referral GuidanceReferral Guidance• Immediate

o CES

• Urgentlyo Serious spinal pathologyo Progressive neurological deficit- refer after 1 weeko Nerve root pain not resolving after 6 weeks, to be seen within 3

• Soono Inflammatory conditions suspected e.g. ASo Simple back pain and not resuming activities after 2-3 weeks

QuestionsQuestions1. A 34-year-old man reports the sudden

onset of back pain after bending over to tie his shoe laces. There is tenderness over the lumbar spine on examination and leaning back worsens the pain. Neurological examination and straight leg raising is normal

2. A 76-year-old man reports pain is his buttocks when he walks the dog. The pain comes on after around 500 yards and resolves when he stops. He has a past history of chronic obstructive pulmonary disease and ischaemic heart disease. Neurological examination is normal and the foot pulses are difficult to feel in both feet

3. A 68-year-old man obese man presents with a one day history progressively severe lower back pain. There was no obvious trigger. Abdominal examination is unremarkable. Blood pressure is 90/60 mmHg and his pulse is 120 bpm

• Select from the following• A. Peripheral arterial

disease• B. Prolapsed disc• C. Facet joint pain• D. Perforated duodenal

ulcer• E. Ruptured abdominal

aortic aneurysm• F. Pyelonephritis• G. Ankylosing

spondylitis• H. Rheumatoid arthritis• I. Crush fracture• J. Spinal stenosis

QuestionsQuestions• A 65-year-old man presents with bilateral leg pain that

is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis?

A. Inflammatory arachnoiditisB. Peripheral arterial diseaseC. Raised intracranial pressureD.Spinal stenosisE. Lumbar vertebral crush fracture