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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 B1

Low back pain: diagnostic strategy model

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Table B1

Low back pain: diagnostic strategy model

  • Q. Probability diagnosis

  • A. Vertebral dysfunction esp. facet joint and IV disc (‘mechanical’) Musculoligamentous strain/sprain

     Spondylosis (degenerative OA)

  • Q. Serious disorders not to be missed

  • A. Vascular

    • ruptured aortic aneurysm

    • retroperitoneal haemorrhage (anticoagulants)

     Infection

    • osteomyelitis

    • epidural abscess

    • septic discitis

    • tuberculosis

    • pelvic abscess/PID

    • pyelonephritis

     Cancer

    • pancreas

    • myeloma

    • metastases

     Cauda equina compression

     Osteoporotic compression fracture

  • Q. Pitfalls (often missed)

  • A. Spondyloarthropathies

    • ankylosing spondylitis

    • reactive arthritis

    • psoriasis

    • bowel inflammation

     Sacroiliac dysfunction

     Spondylolisthesis

     Claudication

    • vascular

    • neurogenic

     Prostatitis

     Endometriosis

  • Q. Seven masquerades checklist

  • A. Depression, spinal dysfunction, UTI

  • Q. Is this patient trying to tell me something?

  • A. Quite likely many yellow flags. Consider lifestyle, stress, work problems, malingering, conversion reaction

Note: Associated buttock and leg pain included.

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 ...

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