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Back pain

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This section includes low (lumbosacral) back pain and thoracic back pain.

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Low back pain (LBP)

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The most common cause of LBP presenting to the doctor is dysfunction of the spinal intervertebral joints (mechanical back pain or back strain/‘sprain’) due to injury. This problem accounts for ∼72% of cases of LBP, while lumbar spondylosis (degenerative osteoarthritis) is responsible for ∼10% of cases of painful backs presenting to the GP. Musculoligamentous strain is common but usually settles in days. The management of back pain depends on the cause.

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Table B1

Low back pain: diagnostic strategy model

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Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on palpation—central and lateral.

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The movements of the lumbosacral spine with normal ranges are:

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  • extension 20°–30°

  • forward flexion 75°–90°

  • lateral flexion (left and right) 30°

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Perform a neurological and vascular examination of the lower limb/s if pain.

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This should be conservative, especially in the absence of red flags. Basic screening is:

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  • FBE

  • ESR/CRP

  • urinalysis

  • serum alkaline phosphatase

  • PSA in males 50–75 years

  • plain X-ray if chronic pain and red flags

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Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).

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Summary of diagnostic guidelines for spinal pain
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  • Continuous pain (day and night) = neoplasia, esp. malignancy or infection.

  • The big primary malignancy is multiple myeloma.

  • The big 3 metastases are from lung, breast and prostate.

  • The other 3 metastases are from thyroid, kidney/adrenal and melanoma.

  • Pain with standing/walking (relief with sitting) = spondylolisthesis.

  • Pain (and stiffness) at rest, relief with activity = inflammation.

  • In a young person with inflammation think of ankylosing spondylitis, Reiter syndrome or reactive arthritis. Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.

  • Pain provoked by activity, relief with rest = mechanical dysfunction.

  • Pain in bed at early morning = inflammation, depression or malignancy/infection.

  • Pain in periphery of limb = ...

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