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:
- Reported multiple or chronic joint pain
- Reported single acute painful swollen joint
- Reported back pain (which is discussed below)
Contents
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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