Lower Back Pain

1
Lower Back Pain
2
Definitions

• Most backache is mechanical low back pain
• Symptoms cannot be ascribed to a pathology
  (infection, tumour, osteoporosis, fracture,
  radicular syndrome)
• Radicular nerve root pain
• Acute - lt6 weeks, sub-acute 6-12 weeks, chronic
  gt 12 weeks
• Recurrent New episode after pain free for 6
  months
• Affects 80-90 men and women between 30 and 50.

3
Presentation

• History

• Red Flags

• Consider occupation, hobbies or sport
• PMH
• Steroid predisposes to osteoperosis
• History of malignancy/myeolma
• Patients management

• Recent Violent Trauma
• Minor trauma with osteoperosis
• lt20 or gt50
• Hx Cancer, drug abuse, HIV, Immunosuppression,
  corticosteroids
• Constitutional symptoms
• Recent bacterial infection
• Pain
• Worse supine, night, thoracic, constant,
  non-mechanical, unchanged despite treatment
• Morning stiffness
• Saddle anaesthesia or bladder/bowel change

4
Examination

• Basics

• Red Flag

• Undressed, revealing spine, standing
• Inspection, palpation, function and brief
  neurology
• More detailed if red flags
• Passive SLR
• For nerve root pain
• Sensitive (90)
• Not specific (20)

• Structural Deformity
• Severe/progressive deficit
• Laxity of anal sphincter
• Perianal/perineal sensory loss
• Major Motor Weakness
• Cauda Equina
• Bladder dysfunction
• Sphincter disturbance
• Saddle anaesthesia
• Lower limb weakness
• Gait disturbance

5
Differential Diagnosis

• Peripheral Arterial Disease
• Pain on walking, relieved by rest
• Absent or weak pulses
• Include smoking and other vascular disease
• Infection
• Never forget TB (osteomyelitis)
• HIV predisposes infections
• Pyelonephritis
• Dissecting aortic aneurysm
• Pain in back radiating through to front

• Facet Joint
• Acute or chronic
• Worse morning/standing
• Pain over facets worse on extension
• Spinal Stenosis
• Gradual onset
• Unilateral/bilateral leg pain, numbness worse on
  walking
• Resolves on sitting/leaning forwards, crouching
  down
• Diagnose with MRI
• Ankylosing Spondylitis
• Young man with lower back pain and stiffness
• Improves with activity
• Peripheral arthritis

6
Investigations

• If simple low back pain no investigation required
• Plain XR
• 120 CXRs, rarely affects management. Should not
  be used routinely
• Fracture suspected
• Metastatic carcinoma (prostate sclerotic),
  (lung, thyroid, kidney osteolytic), (breast
  both)
• Collapse in osteoperosis
• Pagets disease
• CT Scan
• Best for spondylolisthesis and stress fractures
• MRI
• Good picture of soft tissues, will show nerve
  compression
• Displays disc lesions best
• Bloods
• FBC, ESR, CRP cancer, infection, inflammation
• LFTS - ?ALP in metastatic disease and pagets
• PSA Prostate carcinoma
• Urine hydroxyproline Increased in Pagets

7
Management

• Low Back Pain
• Information, reassurance and advice NOT BED
  REST, Stay Active!
• Regular pain relief
• Referral
• Consider physical treatments, manipulation if not
  resuming normal activities after a week or two.
• MDT approaches CBT and back schools
• Red Flag
• Urgent refrral e.g. Cauda Equina to neuro/spinal
  surgeon

• Chronic Pain, psychosocial factors and yellow
  flags
• Belief that activity is harmful
• Sickness behaviour
• Social withdrawal
• Emotional problems
• Problems at work
• Claims, compensation etc.
• Overprotective family
• Inappropriate expectations of Rx (including low)
• Try and challenge behaviours

8
Referral Guidance

• Immediate
• CES
• Urgently
• Serious spinal pathology
• Progressive neurological deficit- refer after 1
  week
• Nerve root pain not resolving after 6 weeks, to
  be seen within 3
• Soon
• Inflammatory conditions suspected e.g. AS
• Simple back pain and not resuming activities
  after 2-3 weeks

9
Questions

1. A 34-year-old man reports the sudden onset of
   back pain after bending over to tie his shoe
   laces. There is tenderness over the lumbar spine
   on examination and leaning back worsens the pain.
   Neurological examination and straight leg raising
   is normal
2. A 76-year-old man reports pain is his buttocks
   when he walks the dog. The pain comes on after
   around 500 yards and resolves when he stops. He
   has a past history of chronic obstructive
   pulmonary disease and ischaemic heart disease.
   Neurological examination is normal and the foot
   pulses are difficult to feel in both feet
3. A 68-year-old man obese man presents with a one
   day history progressively severe lower back pain.
   There was no obvious trigger. Abdominal
   examination is unremarkable. Blood pressure is
   90/60 mmHg and his pulse is 120 bpm

• Select from the following
• A. Peripheral arterial disease
• B. Prolapsed disc
• C. Facet joint pain
• D. Perforated duodenal ulcer
• E. Ruptured abdominal aortic aneurysm
• F. Pyelonephritis
• G. Ankylosing spondylitis
• H. Rheumatoid arthritis
• I. Crush fracture
• J. Spinal stenosis

10
Questions

• A 65-year-old man presents with bilateral leg
  pain that is brought on by walking. His past
  medical history includes peptic ulcer disease and
  osteoarthritis. He can typically walk for around
  5 minutes before it develops. The pain subsides
  when he sits down. He has also noticed that
  leaning forwards or crouching improves the pain.
  Musculoskeletal and vascular examination of his
  lower limbs is unremarkable. What is the most
  likely diagnosis?
• Inflammatory arachnoiditis
• Peripheral arterial disease
• Raised intracranial pressure
• Spinal stenosis
• Lumbar vertebral crush fracture