Back Complaint

Low back pain (LBP) is a common complaint in primary care and can result from a variety of musculoskeletal and neurological conditions. Here’s an overview of the diagnosis and management of low back pain, including red flags that may indicate a more serious underlying condition.

Diagnosis:

  1. History:
    • Onset: Acute (<4 weeks), Subacute (4-12 weeks), or Chronic (>12 weeks).
    • Location: Central, unilateral/bilateral, radiating.
    • Quality: Dull, sharp, burning.
    • Intensity: Scale of 1-10, impact on daily activities.
    • Aggravating/Alleviating Factors: Movements, positions, activities.
    • Associated Symptoms: Leg pain, numbness, tingling, weakness.
  2. Physical Examination:
    • Inspection: Posture, deformity, or curvature.
    • Palpation: Tenderness over vertebral column or muscles.
    • Range of Motion: Flexion, extension, lateral bending, and rotation.
    • Neurologic Examination: Reflexes, muscle strength, sensory examination.
    • Special Tests: Straight leg raise test.
  3. Red Flags:
    • Weight Loss: Unintentional weight loss can be a sign of cancer.
    • Fever: Possible infection or malignancy.
    • Trauma: Recent significant trauma or minor trauma in people with osteoporosis.
    • Neurological Deficits: Major motor weakness, saddle anesthesia, changes in bowel or bladder function can indicate cauda equina syndrome.
    • Age: New onset LBP in individuals <20 or >50 years old warrants a closer look.
    • History of Cancer: Any history of cancer increases the risk of metastases.
    • IV Drug Use or Immunocompromise: Increases the risk of spinal infection.
    • Prolonged Corticosteroid Use: Increases risk of osteoporotic fractures.
    • Nighttime Pain: Pain that wakes you up at night can be a red flag for cancer or infections.
  4. Imaging:
    • Not typically required for acute LBP unless red flags are present.
    • X-rays: May be indicated if there is a history of trauma, cancer, or suspicion of structural abnormalities.
    • MRI or CT scan: Consider if cauda equina syndrome or other neurologic findings are suspected, or if symptoms persist despite conservative treatment.
  5. Blood Tests:
    • May include FBC, CRP, ESR, UEC, LFT, especially if infection or systemic disease is suspected.

Management:

  1. Conservative Treatment:
    1. Education: Reassurance that prognosis is generally good and that maintaining activity is beneficial.
    2. Physical Activity: Encourage staying active within pain tolerance.
    3. Heat or Cold Therapy: Can be used for symptom relief.
    4. TENS: Can be used for symptom relief.
    5. Physiotherapy: Exercises to strengthen the back and core muscles, improve flexibility and posture.
  2. Medications:
    • Over-the-counter pain relievers like ibuprofen or paracetamol.
    • Muscle relaxants if there is significant muscle spasm.
    • For severe pain, short-term use of narcotics may be considered under careful supervision.
  3. Interventional Treatment:
    1. Epidural Steroid Injections: For radicular pain, if conservative management fails.
    2. Surgery: Rarely required for acute LBP but may be necessary for cauda equina syndrome, significant neurological deficits, or intractable pain.

Chronic Low Back Pain Management:

  • BIO-PSYCHO-SOCIAL
  • Multidisciplinary approach including
    • medication,
    • physiotherapy, and
    • psychological therapies like CBT
  • Interventional procedures or surgery may be considered in selected patients.

Follow-up:

  • Regular follow-up to monitor symptoms.
  • If initial conservative management fails, consider referral to a specialist.

Prevention:

  • Exercise regularly to keep the back muscles strong.
  • Practice good posture.
  • Use proper lifting techniques.
  • Maintain a healthy weight.

In managing LBP, it’s crucial to individualize treatment plans according to the patient’s specific situation, preferences, and response to initial therapies, always keeping in mind the potential for more serious underlying conditions as indicated by red flag symptoms.

Back pain is a common issue that can arise from a variety of causes. It’s important to approach its diagnosis and management systematically. Here’s a comprehensive overview:

Causes of Back Pain

  • Musculoskeletal Causes:
    • Strain or sprain of muscles and ligaments (most common)
    • Degenerative changes, like osteoarthritis
    • Herniated or bulging discs
    • Compression fractures
    • Scoliosis, kyphosis
  • Neurological Causes:
    • Sciatica (irritation of the sciatic nerve)
    • Spinal stenosis (narrowing of the spinal canal)
    • Neuropathy
  • Inflammatory Causes:
    • Ankylosing spondylitis
    • Rheumatoid arthritis
  • Infectious Causes:
    • Osteomyelitis (bone infection)
    • Discitis (inflammation of the intervertebral disc)
  • Neoplastic Causes:
    • Primary or metastatic tumors
  • Referred Pain:
    • Kidney stones or infections
    • Pancreatitis
    • Aortic aneurysms
  • Other Causes:
    • Psychosomatic back pain
    • Pregnancy

Diagnosis

  • History (Hx):
    • Character, location, and duration of pain
    • Aggravating and relieving factors
    • History of trauma, overuse
    • Neurological symptoms (numbness, weakness, bowel/bladder dysfunction)
    • Systemic symptoms (fever, weight loss, night sweats)
    • Past medical history, including chronic illnesses and cancer
  • Physical Examination (Ex):
    • Inspection and palpation of the spine
    • Range of motion assessment
    • Neurological examination (reflexes, muscle strength, sensation)
    • Special tests:
      • Straight leg raise test for sciatica,
      • Schober’s test for ankylosing spondylitis 10 above + 5 below L5 = 15cm -> 20cm with forward flexion
  • Investigations (Ix):
    • X-rays for trauma, structural abnormalities
    • MRI or CT scan for detailed assessment of discs, nerves, soft tissues
    • Blood tests (CBC, ESR, CRP) for infection or inflammatory conditions
    • Bone scan or PET for suspected malignancy

Differential Diagnosis (DDx)

  • Musculoskeletal Issues (e.g., muscle strain, herniated disc)
  • Neurological Disorders (e.g., radiculopathy, spinal stenosis)
  • Inflammatory Diseases (e.g., ankylosing spondylitis)
  • Malignancy (e.g., spinal tumor)
  • Infections (e.g., vertebral osteomyelitis)
  • Referred Pain (e.g., renal causes, abdominal issues)

Management (Mx)

  • Conservative Treatment:
    • Pain management: NSAIDs, paracetamol
    • Muscle relaxants for spasms
    • Physical therapy and exercises
    • Weight management, if applicable
  • Interventional Treatments:
    • Epidural steroid injections for radicular pain
    • Nerve blocks or radiofrequency ablation in selected cases
  • Surgical Intervention:
    • Indicated for severe cases like cauda equina syndrome, significant neurological deficits, or failure of conservative treatment
    • Procedures: Discectomy, laminectomy, spinal fusion
  • Alternative Therapies:
    • Acupuncture
    • Chiropractic manipulation (in selected cases)
  • Lifestyle Modifications:
    • Ergonomic adjustments in daily activities
    • Regular exercise, including stretching and strengthening
    • Stress management techniques
  • Follow-up and Monitoring:
    • Regular follow-up to monitor progress
    • Adjustments in therapy as needed
  • Referral:
    • Referral to specialists like orthopedists, neurosurgeons, or rheumatologists in complex cases
  • Patient Education
    • Importance of posture and ergonomics
    • Safe exercise techniques
    • Weight management strategies

Each patient’s treatment plan should be tailored to their specific circumstances, considering the cause of the back pain, the severity of symptoms, and any underlying health conditions. Regular follow-up is important to assess the effectiveness of treatment and to make any necessary adjustments.