Back Pain

Back pain is a huge problem for many patients world-wide.  The incidence in the general population is 5% and the lifetime prevalence is 60-90%.  Most of these patients have chronic or relapsing symptoms and most will not have a specific diagnosis made.

The causes of back pain are many: the main issue when seeing a patient with back pain is to differentiate between ‘organic’ and ‘non-organic’ causes and to identify any ‘red-flag’ symptoms/signs:

  • Age <20 or >70
  • PMHx of neoplasia or osteoporosis
  • Unexplained weight loss
  • Fever/rigors
  • Constant pain that’s worse at night
  • Acute onset of incontinence (fecal or urinary) or urinary retention
  • Loss of perineal sensation
  • Global and progressive weakness of the lower limbs

Differential Diagnosis

Young Adults

Mechanical back pain; prolapsed disc; spondylolisthesis; Fracture; Ankylosing Spondylitis; Infection

Middle-aged

Mechanical back pain; prolapsed disc; Spondylolisthesis; Rheumatoid Arthritis; Spinal Stenosis; Tumours; Infection

Elderly

Degenerative Spinal Disease; Spinal Stenosis; Spondylolisthesis; Osteoporosis; Neoplasia/tumours; Infection

Management (non-emergency/urgent cases)

1st line treatment remains advice and reassurance: minimal bed rest; low stress aerobic exercise and minimal disruption to activities of daily living (ADL).  Most cases of mechanical back pain will resolve within 1 month.  If pain is impeding ADLs, persists for longer than one month (assuming it is not worse and more serious pathology has been excluded) or the patient is relapsing frequently, simple regular analgesia (paracetamol +/- NSAIDs) is usually effective.  Altering the strength of analgesia should be done following the analgesic ladder.

Surgery should only be considered 3rd line in patients who are fit and able.  Much of the surgery done for back pain is not highly successful.

History

  • Wash hands, introduce self, check patient name and DOB, establish rapport and gain consent
  • HPC
    • Timing
      • e.g. acute onset associated with heavy lifting (mechanical)
      • acute onset after coughing/sneezing or twisting or after earlier strain (prolapsed disc/spondylolisthesis)
      • gradual onset (stenosis/tumour)
    • Radiation/associated sensory features
      • Buttocks/back of leg- sciatica (prolapsed disc/spondylolisthesis)
      • Saddle anaesthesia- Red flag for cauda equina (anterior prolapse)
      • Foot/inner thigh numbness
    • Exacerbating/alleviating factors/positions
      • e.g. walking uphill (stenosis)
    • Other symptoms
      • Fever (infection)
      • Incontinence- another red flag for cauda equina
      • Leg weakness
        • NB paralysis is another red flag
  • You also want details in the rest of the history e.g. FHx back problems, Employment involving heavy lifting; previous back injury/trauma/conditions/surgery etc;

Back Examination

Neurological examination of the lower limbs- motor / sensory

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