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This section includes low (lumbosacral) back pain and thoracic back pain.
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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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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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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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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.
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The big primary malignancy is multiple myeloma.
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The big 3 metastases are from lung, breast and prostate.
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The other 3 metastases are from thyroid, kidney/adrenal and melanoma.
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Pain with standing/walking (relief with sitting) = spondylolisthesis.
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Pain (and stiffness) at rest, relief with activity = inflammation.
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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.
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Pain provoked by activity, relief with rest = mechanical dysfunction.
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Pain in bed at early morning = inflammation, depression or malignancy/infection.
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Pain in periphery of limb = discogenic → radicular
or vascular → claudication
or spinal canal stenosis → claudication.
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Pain in calf (ascending) with walking = vascular claudication.
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Pain in buttock (descending) with walking = neurogenic claudication.
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One disc lesion = one nerve root (exception is L5–S1 disc). One nerve root = one disc (usu.).
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Two or more nerve roots—consider neoplasm.
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The rule of thumb for the lumbar nerve root lesions is L3 from L2–3 disc, L4 from L3–4, L5 from L4–5 and S1 from L5–S1.
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A large disc protrusion can cause bladder symptoms, either incontinence or retention.
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A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.
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Red flag pointers for back pain
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age >50 years and <20 years
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history of cancer
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temperature >37.8°C; night sweats
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constant pain—day and night
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unexplained weight loss
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significant trauma (e.g. MVA)
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osteoporosis ♀ >50 years; ♂ >60 years
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use of anticoagulants and corticosteroids
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drug or alcohol abuse esp. IV drug use
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no improvement over 1 month
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neurological deficit
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possible cauda equina syndrome
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Vertebral dysfunction with non-radicular pain (non-specific LBP)
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The common cause of LBP
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Usu. due to dysfunction (injury) of the pain-sensitive facet joint ± a minor disc disruption
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Pain usu. unilateral; can be central or bilateral
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No investigations needed for acute pain <2 wks if no red flags
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Management—acute LBP (only) without spasm
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No bed rest—normal daily activities; keep active, return to work if possible
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Back education
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Regular simple analgesics (e.g. paracetamol, ibuprofen or aspirin)
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Exercise program (when exercises do not aggravate)
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Swimming (if feasible)
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NSAIDs: 14 d (only if evidence of inflammation)
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Spinal stretching, mobilisation or manipulation if needed after review in 4–5 d
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Most of these patients can expect to be relatively pain free and able to return to work within 14 d.
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Chronic LBP (pain >3 mths)
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Consider: plain X-ray, ESR, urine analysis, PSA (♂ >50 yrs)
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Back education
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Normal activities
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Analgesics or paracetamol
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NSAIDs: 14 d (if inflammation)
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Exercise program
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Trial of mobilisation/manipulation (if untried) × 3, if no contraindications
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Referral for physiotherapy
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Consider amitriptyline 10–25 mg (o) nocte increasing to max 75–100 mg
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Vertebral dysfunction with radiculopathy (sciatica)
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If abnormal neurological signs (e.g. foot drop) investigate with plain X-ray, CT scan ± MRI.
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Sciatica is a more complex and protracted problem to treat, but most cases will gradually settle within 12 wks if the following approach is used:
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Relative rest for up to 3 d at onset (keep the spine straight—avoid sitting in soft chairs and for long periods)
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Resume activity ASAP
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Regular non-opioid analgesics with review as the patient mobilises
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NSAIDs: 14 d
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If severe unrelieved pain add tramadol 50–100 mg (o) 2–4 times daily (max. 400 mg/day) as necessary, for short-term use
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Consider steroids for acute severe pain, e.g. prednisolone 50 mg for 5 d → 25 mg → taper to 0 (3 wks total)
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Back education
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Exercises—straight-leg raising exercises to pain tolerance
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Swimming
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Traction (with care)
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Epidural anaesthesia (if slow response)
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Guidelines for possible surgical intervention
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The most common disc prolapses are L4–5, L5–S1.
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Bladder/bowel disturbances
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Progressive motor disturbance (e.g. increased foot drop, quadriceps weakness)
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Intense prolonged pain with no reponse to 6 weeks treatment and imaging shows a lesion corresponding to symptoms
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>50 yrs: ↑ with age
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Dull nagging LBP
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Stiffness, esp. in mornings (main feature)
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Aggravated by heavy activity, bending (e.g. gardening)
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Relief by gentle exercise, hydrotherapy
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All movements restricted
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Note: Tends to cause spinal canal stenosis with neurogenic claudication, which responds well to surgical decompression.
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Basic analgesics (depending on patient response and tolerance)
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NSAIDs (judicious intermittent use)
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Appropriate balance between light activity and rest
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Exercise program and hydrotherapy (if available)
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Regular mobilisation therapy may help
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Consider trials of electrotherapy, such as TENS and acupuncture
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About 5% of the population have spondylolisthesis but not all are symptomatic. The pain is caused by extreme stretching of the interspinous ligaments or of the nerve roots, or a disc lesion.
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Diagnosis is confirmed by lateral X-ray (Fig. B2).
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Strict flexion exercise program for at least 3 mths (avoid hyperextension)
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Passive spinal mobilisation may help some
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Lumbar corsets help but avoid if possible
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Surgery is last recourse
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The spondyloarthropathies
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The seronegative spondyloarthropathies are a group of disorders characterised by involvement of the sacroiliac joints with an ascending spondylitis and extraspinal manifestations such as oligoarthritis and enthesopathies (
See the spondyloarthropathies).
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Young men 15–30
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Aching throbbing pain of inflammation
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LBP radiating to buttocks
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Back stiffness, esp. in mornings
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Absent lumbar lordosis
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Positive sacroiliac stress tests
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The earlier the treatment the better the outlook for the patient; the prognosis is usu. good.
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Advice on good back care and posture
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Exercise programs to improve the range of movement
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Drug therapy, esp. tolerated NSAIDs (e.g. indomethacin)
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Sulfasalazine—a useful second-line agent if the disease progresses despite NSAIDs. Consider methotrexate and other DMARDs.
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Thoracic (dorsal) back pain which is common in people of all ages is mainly due to dysfunction of the joints of the thoracic spine, with its unique costovertebral joints.
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Muscular and ligamentous strains may be common, but rarely come to light in practice because they are self-limiting and not severe.
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This dysfunction can cause referred pain to various parts of the chest wall and can mimic the symptoms of various visceral diseases, such as angina, biliary colic and oesophageal spasm.
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Intervertebral disc prolapse is very uncommon in the thoracic spine and then occurs below T9, usu. T11–12, but it is a target for bony metastases (see red flags) and ‘not to be missed’ disorders for LBP.
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Age 11–17
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Males > females
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Lower thoracic spine T9–12
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Thoracic pain or asymptomatic
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Increasing thoracic kyphosis over 1–2 mths
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Cannot touch toes
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Diagnosis confirmed by X-ray (Schmorl's nodes etc.)
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Explanation and support
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Extension exercises, avoid forward flexion
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Postural correction
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Avoidance of sports involving lifting and bending
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Consider bracing or surgery if serious deformity
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Idiopathic adolescent scoliosis
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The vast majority of curves, occurring equally in boys and girls, are mild and of no consequence. 85% of significant curves in adolescent scoliosis occur in girls. Such curves appear during the peripubertal period, usu. coinciding with the growth spurt. The screening test (usu. in 11–13 yo) is to note the contour of the back on forward flexion. 10% of normal adolescents have a curve of >5% but only 1–2% >10%.
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A single erect PA spinal X-ray is sufficient; the Cobb angle is the usual measurement yardstick.
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Preserve good appearance—level shoulders and no trunk shift
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Prevent increasing curve in adult life: <40°
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Not to produce a straight spine on X-ray
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Refer for expert opinion
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General rules for Cobb angle
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<20° observe
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20–40° brace
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>40° surgery
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Kyphosis is the normal curve of the thoracic spine when viewed from the side. The normal range is 20–45° with the angle measured between the uppermost and lowermost inclined vertebrae on the lateral X-ray. An excessive angle (>45–50°) occurs with a kyphotic deformity which usually presents in childhood and is congenital. Consider referral if >50°.
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Dysfunction of the thoracic spine
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Also called thoracic hypomobility syndrome, this is the outstanding cause of pain (often interscapular) presenting to the practitioner, is relatively easy to diagnose and usu. responds dramatically to a simple spinal manipulation treatment (beware of spinal disease, esp. osteoporosis).
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Association: chronic poor posture
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Diagnosis confirmation: examination of spine, X-ray (mainly to exclude disease)
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Continued activity if pain permits
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Explanation and reassurance
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Back education program
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Spinal manipulation (very effective)
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Spinal mobilisation (if manipulation contraindicated)
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Simple analgesics as required
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Exercise program, esp. extension exercises
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Posture education