Back Pain

Examination, assessment, red flags,

Good Back Guide.

Jon Dixon, Bradford VTS

Causes of back pain 1

Mechanical - Muscles and ligaments

Local tenderness, muscle spasm, loss of lumbar lordosis, percussion tenderness over spinous process

NO MOTOR/SENSORY/REFLEXIC LOSS

Causes of back pain 1

Causes of low back pain 2

Radicular low back pain Herniated intervertebral disc commonest cause

but can be foraminal stenosis sec. OA / tumours / infection (rare)

TOP TIP not all pain referred down leg is sciatica (facet joint disease / hip / SIJ / piriformis syndrome etc.)

Structures that cause nerve root compression

L4/L5/S1 Radiculopathy

Straight Leg Raising

Piriformis syndrome

Pain from piriformis muscle – irritation of sciatic nerve passing deep or through it

Pain on resisted abduction / external rotation of leg

Causes of low back pain 3

Lumbar Spinal Stenosis Subtle presentation. Bilateral radicular signs should alert to

possibility. Pain on walking- worse on flat –(eases if

hunched over – shopping trolley sign!) Can be mistaken for Claudication. Admit if progressive / or else CT scan.

Cauda Equina syndrome (spinal canal compression)

Spinal Stenosis

Causes of low back pain 4

Inflammatory – Ankylosing Spondylitis

Difficult to diagnose if early stages but: Morning stiffness for > 30 minutes Pain that alternates from side to side of lumbar spine Sternocostal pain Reduced chest expansion

Schobers test

Schobers Test

Fabere test

Pelvic Compression Test

Red Flags

Weight loss, fever, night sweats History of malignancy Acute onset in the elderly Neurological disturbance Bilateral or alternating

symptoms Sphincter disturbance Immunosuppression Infection (current/recent) Claudication or signs of peripheral ischaemia Nocturnal pain

Yellow flags 1

Yellow Flags 2

Factors prolonging back pain Internal factors-Opioid dependency “External controller” patient-type; learned

helplessness; factitious disorder Mental health- depression or anxiety Interpersonal factors "Sick role“ Stressors in relationships Environmental / societal factors- Disability

payments / Litigation / Malingering

Causes of back pain

Structural Mechanical

Facet joint arthritisProplapsed intervertebral discSpondylolysis / Spinal stenosis

Inflammatory SacroiliitisSpondyloart

hropathies

Infection Metabolic Osteoporotic

vertebral collapsePaget's diseaseOsteomalacia

NeoplasmCa ProstateCa Breast

Referred pain

•Pleuritic pain

•Upper UTI / renal calculus

•Abdominal aortic aneurysm

•Uterine pathology (fibroids)

•Irritable bowel (SI pain)

•Hip pathology

Imaging modalities

Xrays good first line Ix if red flags, osteoporotic fracture

Bone scan (also good initial Ix if Xray nad and red flags) - mets, infection, pagets, PMR

CT Scan bone tumours fractures and spinal stenosis

MRI spinal cord, nerve roots, discs, haemorrhage

Dexa Scan Bone density

TREATMENTS Simple Back Pain

(over 95% of cases)Aim: to relieve symptoms and mobilise early.

Avoid Bed restParacetamol (+nsaid if insufficient)Avoid opiates if at all possibleNo evidence that co-analgesics better than

paracetamol alone.Muscle relaxants (diazepam / methocarbamol) small

additional benefit.

No evidence for:

Short wave diathermyTENSSpinal manipulationTractionAcupunctureExercisesSpinal cortisone injections

Occupational issues

Occupational issues

More sick leave : Less chance of recovery4-12 w - 40% chance of still being off at 1

year.Don’t need to be pain free to return to

work MDT Rehabilitation programs:

psychological therapies; CBT; graduated return to work (light duties)

Blocks to returning to work (blue flags!)

perceived work loadlow paymanagement attitudespoor supportloss of confidencedepression

JD’s top tips for back pain.

Patient who attends a second time with “simple” back pain- get them to strip to their underwear!

Top tips

True sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.

Top tips

With radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)

Top Tips

Physios are very good at managing the psychological aspects of chronic pain.

Top Tips

Sending someone to casualty is pointless but can have a very useful ‘placebo’ effect in showing the patient how impressed you are with his or her pain.