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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 non-specific back pain) 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.
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 = discogenic → radicular
or vascular → claudication
or...