Back PainBack PainBack PainBack PainAlastair JonesAlastair JonesAlastair JonesAlastair Jones

Back PainBack PainBack PainBack Pain

•Back pain is a very common problem that will affect most people at some point during their lives.

•90% is musculoskeletal / non serious and will get better within 8-12 weeks. It can be treated with analgesia and keeping mobile.

•Need to identify the 10% with serious pathology

Musculoskeletal Back Musculoskeletal Back PainPain

Musculoskeletal Back Musculoskeletal Back PainPain

•Commonly lower back pain. It may occur gradually due to years of poor posture.It may develop suddenly after lifting or awkward movement. Sometimes it can develop for no identifiable reason...

•Upper or middle back pain is less common due to the more limited mobility of the spine at that level. However a trapped or injured nerve can cause pain still.

•Whilst it may not be serious it can be very debilitating for the patient and expensive to both the NHS and the economy as a whole.

Musculoskeletal Back Musculoskeletal Back PainPain

Musculoskeletal Back Musculoskeletal Back PainPain

•Risk factors:

•Being overweight

•Smoking

•Pregnancy

•Steroids (osteoporosis)

•Stress

•Depression

Musculoskeletal Back Musculoskeletal Back PainPain

Musculoskeletal Back Musculoskeletal Back PainPain

•Presentation - lower back pain, no specific cause. Pain is dull, diffuse, poorly localised. No neurology on examination, -ve SLR and rare to get pain beyond knee. May be secondary to OA, degenerative, sprains and strains, fibromyalgia. Often recurrent.

•Serious pathology more likely if skeletal pain, neurology or extra-spinal pathology

Serious CausesSerious CausesSerious CausesSerious Causes•Skeletal:

•Fractures

• Infection - abscess, discitis, osteomyelitis

•Malignancy

•Nerve syndromes:

•Disc herniation - CES, root impingement

•Canal stenosis

•Arthritis

Serious CausesSerious CausesSerious CausesSerious Causes•Extra-spinal:

•AAA

•Renal calculi / UTI

•appendicitis / psoas abscess / rectal cancer

•Endometriosis / PID / ovarian cysts

•Lymphoma / lymph node enlargement / cancer

Essential QuestionsEssential QuestionsEssential QuestionsEssential Questions

•Where is the worst pain? Where is your pain?

•When did you last pass urine / open bowels?

•Does your bottom / genital area feel normal?

•Can you feel a full bladder? Any urine incontinence?

•Can you tighten your anus?

Essential ExaminationEssential ExaminationEssential ExaminationEssential Examination

•Neurology - tone, power, sensation, reflexes, SLR

•ROM spine

•PR - anal tone and sensation

•Post void residual volume

Red FlagsRed FlagsRed FlagsRed Flags

Back Pain - Red FlagsBack Pain - Red FlagsBack Pain - Red FlagsBack Pain - Red Flags•Hx of cancer or recent infection

•Immunosuppressed - HIV, IVDU, steroids, chemotherapy, transplant patients...

•Age < 20 or > 55

•Bilateral sciatica symptoms

•Bowel or bladder dysfunction

•Saddle or genital paraesthesia

Back Pain - Red FlagsBack Pain - Red FlagsBack Pain - Red FlagsBack Pain - Red Flags

•Trauma

•Foot drop or other discrete neurology

•Systemic illness - fever, malaise, wt loss

•Loss of anal tone

•Retention - PVR > 100 mls

•Significant leg weakness

InvestigationsInvestigationsInvestigationsInvestigations

•If no red flags...

•Otherwise may require:

•bloods

•radiology - USS/CT/MRI

ManagementManagementManagementManagement

•Non serious back pain can usually be managed conservatively:

•Analgesia

•Mobilisation / physiotherapy / gentle exercise

•Education / information leaflets

•GP management

Disc DiseaseDisc DiseaseDisc DiseaseDisc Disease

•50%resolve / back to work after 2 months

•90% resolved after 6 months

•Consider surgery after 2 months if sciatica symptoms not improving. Surgery ineffective for LBP

•Conservative vs surgery - 90% good outcome at 6 months

Protruding DiscsProtruding DiscsProtruding DiscsProtruding Discs

Corda Equina Corda Equina SyndromeSyndrome

Corda Equina Corda Equina SyndromeSyndrome

•Severe LBP

•Bilateral sciatica

•Lose L5/S1

•Bladder or bowel dysfunction

•Saddle paraesthesia

Corda Equina Corda Equina SyndromeSyndrome

Corda Equina Corda Equina SyndromeSyndrome

•Have a high index of suspicion if any red flags

•Needs emergency MRI / speciality referral

•Outcome for bowel / bladder / sexual function better if decompressed within 48 hours. However, sooner the better!

Other Serious CausesOther Serious CausesOther Serious CausesOther Serious Causes

•Maintain a high index of suspicion. Non-serious back pain is a diagnosis of exclusion.

•Do investigate for ?AAA, fracture etc as indicated by history and examination. These should managed as is appropriate.

Wedge FractureWedge FractureWedge FractureWedge Fracture

•Easy to miss so look carefully!

AAAAAAAAAAAA

•Need to rule out as people get older...

Psoas AbcsessPsoas AbcsessPsoas AbcsessPsoas Abcsess

Chronic Back PainChronic Back PainYellow FlagsYellow Flags

Chronic Back PainChronic Back PainYellow FlagsYellow Flags

•ABCDEFW approach which highlights patients at risk of developing chronic back pain

•Attitude - Coping, getting on with it vs Not coping

•Beliefs - do they believe there must be something serious going on. Catastrophisation...

•Compensation - awaiting payment (RTC, work injury)

Chronic Back PainChronic Back PainYellow FlagsYellow Flags

Chronic Back PainChronic Back PainYellow FlagsYellow Flags

•Diagnosis - how was it communicated I.e. Iatrogenic. E.g. "Your spine is crumbling"

•Emotions - anxiety / depression / emotional difficulties more likely to lead to chronicity

•Family - over bearing or under supportive...

•Work - Poor relationship with work more likely to lead to chronicity also

Other ResourcesOther ResourcesOther ResourcesOther Resources

•NICE CG88 for chronic back pain

•The Back Book - useful patient resource available from the stationary office.

QuestionsQuestionsQuestionsQuestions

SummarySummarySummarySummary

•90% of cases are non-serious and better after 2 months

•Analgesia and mobilisation/ physiotherapy

•Remember to exclude serious pathology - infection, malignancy, discs, fracture, AAA, CES...

Summary - Red FlagsSummary - Red FlagsSummary - Red FlagsSummary - Red Flags

Summary - Red FlagsSummary - Red FlagsSummary - Red FlagsSummary - Red Flags•Hx of cancer or recent infection

•Immunosuppressed - HIV, IVDU, steroids, chemotherapy, transplant patients...

•Age < 20 or > 55

•Bilateral sciatica symptoms

•Bowel or bladder dysfunction

•Saddle or genital paraesthesia

Summary - Red FlagsSummary - Red FlagsSummary - Red FlagsSummary - Red Flags

•Trauma

•Foot drop or other discrete neurology

•Systemic illness - fever, malaise, wt loss

•Loss of anal tone

•Retention - PVR > 100 mls

•Significant leg weakness