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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 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.

Table B1Low 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


  • urinalysis

  • serum alkaline phosphatase

  • PSA in males 50–69 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 = discogenic → radicular

    or vascular → claudication

    or spinal canal stenosis → claudication.

  • Pain ...

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