Skip to Main Content

++

Back pain

++

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

++

Low back pain (LBP)

++

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.

++
Table Graphic Jump Location
Table B1

Low back pain: diagnostic strategy model

++ Key examination
++

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

++

The movements of the lumbosacral spine with normal ranges are:

++

  • extension 20°–30°

  • forward flexion 75°–90°

  • lateral flexion (left and right) 30°

+

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

++ Key investigation
++

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

++

  • FBE

  • ESR/CRP

  • urinalysis

  • serum alkaline phosphatase

  • PSA in males 50–75 years

  • plain X-ray if chronic pain and red flags

+

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

++
Summary of diagnostic guidelines for spinal pain
++

  • 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 = ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.