Back Pain

In this article, we cover the assessment and management of back pain. This article forms part of a series on different types of joint pain presentations:

Overview of the Assessment

Back pain is incredibly common and usually, no definite anatomical diagnosis is found (non-specific back pain). During your on-call, your focus will be on recognising serious pathology and relieving pain. However, do consider the huge impact back pain can have with significant physical disability & psychosocial impact. Your aims when assessing back pain include:

  • Recognise serious pathology
    • This includes neurosurgical emergencies, infection (discitis/epidural abscess), malignancy, myeloma, osteoporotic wedge fractures and Paget’s disease
    • Don’t forget about referred pain – an aortic aneurysm could cause thoracic pain.  Pyelonephritis, renal colic and pancreatitis can all cause back pain
  • Relieve pain – see our article on pain relief. Focus on non-pharmacological agents & mobilising for chronic back pain. 
  • Recognise & assess any psychosocial impact 
  • Identify any barriers to recovery (yellow flags)
  • Prevent recurrence & persistence of symptoms

History

  • Site: Asking the patient to point to where the pain is can be helpful
    • Directly overlying the spine suggests a bony cause 
    • Pain between the scapula could be referred pain from a dissecting thoracic aortic aneurysm or a MI 
    • Pain more laterally could be renal, pleuritic or referred from the hip
  • Onset: When did the pain first start?
    • Is this a new pain? If not, what was the diagnosis & management last time?
    • What was the patient doing? Fracture, intervertebral disc pathology and musculoskeletal pain are often associated with trauma (fall, heavy lifting, sudden twisting motion)
    • Gradual or sudden?
  • Character
    • Sharp – spinal fracture
    • Muscle spasm
    • Pleuritic 
    • Neuropathic burning pain – nerve root compression
    • Tearing – aortic dissection
    • Crushing – MI 
  • Radiation 
    • Buttocks or legs – sciatic nerve compression 
    • Limbs – radiculopathy or spinal nerve root compression 
    • Flank to the ipsilateral groin – renal colic 
    • Epigastrium – peptic ulcer disease or pancreatitis 
  • Associated Symptoms
    • Sensory/motor disturbance including bowel & bladder pathology – cord compression 
    • Lower urinary tract symptoms – renal colic or pyelonephritis 
    • Weight loss – malignancy 
    • Early morning stiffness – inflammatory joint disease 
    • Fever/chills – infection, vertebral discitis 
  • Timing: course & whether it is intermittent or continuous
  • Exacerbating/Relieving factors
    • Exertional or improves on rest – OA or fracture 
    • Improves on exercise – inflammatory arthritis 
  • Severity 
    • This helps monitor the response to analgesia
    • Often asking how much their normal activity is limited by the pain helps grade severity
    • What do they do at work? Does the pain affect their job? Can their job be modified to support them going back?
  • Past medical history & family history

Recognising Serious or Sinister Pathology: Red Flags

  • Age above 50 or below 20
  • New back pain or in a new region (particularly if non-lumbar)
  • Any changes to chronic pain
  • Pain at night particularly if it wakes the patient up
  • Constant pain or progressively worsening pain (musculoskeletal pain tends to improve when not moving)
  • Cauda equina syndrome: motor, sensory changes or change in bladder, bowel function. These are late signs where the damage may already be done
  • Malignancy: known malignancy or systemic symptoms such as fever, chills or unexplained weight loss
  • Fracture: prolonged steroid use, known osteoporosis, trauma, focal or bony tenderness
  • Infection: Intravenous drug use, diabetes, immunosuppression, fevers, tuberculosis exposure

Psychosocial Barriers to Rehabilitation that increases the risk of chronic back pain: Yellow Flags

  • Avoiding activity with extended bed rest
  • Psychosocial overlay: mood disorder or social withdrawal
  • Dissatisfaction with work
  • Lack of support or overprotective family
  • Expecting medical input only is required for recovery

Examination

  • General examination
  • Palpate & percuss each spinous process (infection, fracture or malignancy)
  • Look for paraspinal muscle spasm (common in prolapsed discs)
  • Palpate paraspinal muscles for tenderness (common in musculoskeletal causes)
  • Examine the range of movement
  • Neurological examination – check for absent ankle reflexes (slipped disc) or long tract signs in the legs (UMN signs – spasticity, hyperreflexia, Babinski sign)
  • PR examination and test perineal sensation
  • Consider straight leg raise for sciatic nerve compression
  • If malignancy is highly suspected, 

Investigations

  • Usually, no investigations are required for simple back pain
  • Imaging
    • A lumbar x-ray is the equivalent to 120 CXRs, avoid routine scanning
    • Consider a CT scan for stress fractures and spondylolisthesis
    • MRI is better for soft tissue e.g. discitis, suspected malignancy, spinal cord compression. If cord compression is suspected, urgently escalate & read this
  • Bloods including inflammatory markers & bone profile (ALP & calcium)
  • Consider protein electrophoresis for myeloma
  • If suspecting malignancy, consider the more common cancers that affect the spine: multiple myeloma, lung, breast or prostate

Management

  • Advise the patient to stay active
  • Low dose, non-opiate analgesia is best. See our article on pain relief
  • Escalate if any cause apart from non-specific back pain is considered

References & Further Reading

Written by Dr Emma Monteith FY1

Edits by Dr Akash Doshi CT2

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