18.1 Back Pain

Question 1

A 68-year-old woman attends the Pain Management Clinic with a two-year history of pain in her back and
legs.

a) Describe the pharmacological (30%)
with examples, available for this lady.

Answer 1

Pharmacological options:
» Paracetamol, but not to be used alone.

> > NSAIDs – assess risks and benefits, consider need for gastric protection, lowest dose for shortest duration possible.

> > Weak opioid for acute management
if NSAIDs not tolerated,
contraindicated or ineffective.
Not to be used long-term.

> > Amitriptyline, duloxetine,
gabapentin or pregabalin
only if neuropathic component.

Question 2

Describe the other treatment options (40%), with examples, available for this lady.

Answer 2

Other treatment options:
» Self-management.
Reassurance, information,
advice to continue usual
activities and exercise.

> > Exercise, including group NHS classes.

> > Manual therapy as part of
an overall management package.

> > Psychological therapy.
Cognitive behavioural therapy to be
used within a
pain management programme.

> > Pain management programme (PMP):
all interventions combined into one
package of care; education, exercise, relaxation techniques, goal setting, pacing, psychological therapy.

> > Interventional treatments such as
caudal epidural for early treatment
of nerve root pain, facet joint injections or radiofrequency lesioning of
lumbar medial branch.

> > Spinal cord stimulation for radicular pain.

> > Surgery: e.g. laminectomy for spinal stenosis or discectomy for nerve root pain.

Question 3

b) What factors would alert you to the need for further investigation or referral? (30%)**

Answer 3

> > Her age (presentation under 20 or over 55 years old).

> > History of significant trauma.

> > Constant progressive thoracic pain.

> > Past history of cancer,
steroid therapy, intravenous drug abuse
or HIV infection.

> > Unexplained weight loss.

> > Systemically unwell.

> > Cauda equina syndrome
(saddle anaesthesia, gait/sphincter
disturbance).

> > Structural deformity.

> > Marked restriction of lumbar flexion.

> > Non-mechanical pain.

Question 4

3 main causes of back pain and explain

Answer 4

There are three main causes of back pain:

1. > > Musculoskeletal: 95%
   (sacroiliac joint, facet joint, discogenic pain,
   ligamental injury, myofascial pain).

Features: dull, mechanical ache, lumbosacral and buttocks. Referred pain to legs is common but not below knee. Those aged 20– 55 years most affected.

2. > > Nerve root (radicular) pain: 4% (due to disc herniation, spinal stenosis
   and epidural adhesions).

Features: well localised, sharp electric shock pain, typically radiating below the knee. Exacerbated by coughing, straining, sneezing.
Straight leg raise or femoral stretch test will reveal nerve root irritation. Neurological examination may show sensory, motor and
reflex abnormalities.

3. > > Serious spinal pathology: 1%
   (due to trauma, malignancy, inflammatory
   conditions, infection).