What are the causes of mechanical back pain?
- Lumbar muscle sprain/strain: typically causes spasms on movements and sometimes stiffness lasting <30 mins
- Mechanical back pain can be aggravated by movements and certain postures
- Sprain could last for up to 6 weeks
- Bulging, herniated or degenerative intervertebral disc
- Spinal stenosis
- Facet joint disease (osteoarthritis) - worse on twisting
What fractures can cause back pain?
- Spondylolysis is a stress fracture through the pars interarticularis of the lumbar vertebrae
- Spondylolisthesis (vertebral body slippage)
- Vertebral fracture e.g. wedge fractures in osteoporosis
What is pars interarticularis stress fractures?
Spondylolisthesis are common, can be secondary to spondylolysis. Shouldn’t cause a lot of pain or disability. Common in sports people, especially those that do lots of hyperextension movements. Means slippage of the vertebral body.
What is the presentation of spondylolethesis?
- Can happen acutely or insidiously
- More likely to be associated with nerve root symptoms (especially if high degree of slippage) and there may be deformity on examination.
- May have pain on extension of back and tender paraspinal muscles.
What is the presentation of vertebral fractures?
- Ask about height (loss) or posture change (bent over - kyphosis)
- Exam: tenderness
- Osteoporotic fractures can be atraumatic, use FRAX tool
What are the malignant causes of back pain?
- Metastasis related to primary tumour elsewhere - kidney, ovarian, thyroid, lung, prostate, testicular, myeloma, breast
- Myeloma - bone marrow cancer
- Rarer causes include primary tumours e.g. chrondrosarcomas, sarcomas
- Red flags: thoracic back pain, night pain, worse in supine position
What are the infective causes of back pain?
- Discitis
- Osteomyelitis
- TB
- Need to check for immunosuppression - diabetes, medications e.g. steroids or immunosuppressive drugs
- Tenderness, swelling redness
What are the inflammatory/autoimmune causes of back pain?
- Inflammatory spondyloarthropathy e.g. AS
- CTD
- Reactive arthritis
How does sciatica present?
- Disc problem, puts pressure on nerves, get back pain that radiates down buttocks/legs
- Often improves on its own
What is neurogenic claudication?
- Gradual worsening pain that is relieved by bending over/leaning forward
- Caused by stenosis (narrowing) of spinal tunnel - nerve compression
- Typically in >60s
What are the symptoms of cauda equina?
- Starts at L1
- Bilateral sciatica - pain/weakness
- Lower back pain
- Urinary incontinence/retention; faecal incontinence (leaking/soiling)
- Decreased sensation in perianal area (ask about numbness in back passage)
- Decreased anal tone
- Loss of reflexes
- Erectile dysfunction
What are the symptoms of a spinal fracture?
- Sudden onset, severe pain, relieved by lying down
- History of trauma (minor in osteoporosis)
- Structural spinal deformity
- Point tenderness over vertebral body
What are the red flags for cancer?
- > 50yrs
- Gradual onset
- Severe unremitting pain
- Night pain disturbing sleep
- Pain worse coughing/straining/sneezing
- Thoracic pain
- Localised spinal tenderness
- No symptomatic improvement after 4-6 weeks of conservative low back pain therapy
- Unexplained weight loss
- PMH of cancer: some more likely
What are the symptoms of infection in the spine?
- Differentials: discitis, vertebral osteomyelitis, spinal epidural abscess
- Fever
- TB or recent UTI
- Diabetes
- Hx of IV drug use
- HIV infection, use of immunosuppressants or if otherwise immunocompromised
What is the Keele STarT Back Screening Tool (SBST)?
- SBST is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability
- Resulting score stratifies patients into low, medium or high risk
- For each category there is a marked treatment package
- This approach has been shown to reduce back pain related disability and be cost-effective.
What are yellow flags?
Usually social and psychological cues derived from the bio-psychosocial model of illness that may indicate that the patient is at risk of developing chronic back pain.
What is the management of back pain?
- Keep moving
- Be ‘back aware’ making sure of correct posture for lifting and taking care with work not to put unnecessary strain on their back
- Painkillers - NSAIDs and paracetamol, check for contraindications (asthma, GI ulcers)
- Physiotherapy
How would nerve pain present?
Cold to burning, shooting, tingling, numbness or weakness
What are things that patients might want to know about NSAIDs?
- Some evidence of increased CV events with long term use
- Bronchospasm in asthmatics
- Can be associated with renal deterioration
- Not addictive
- Can cause stomach ulcers
