Back Pain

Question 1

Sequence of events

Answer 1

Open question

Timeline

Question 2

Symptom analysis

Answer 2

SOCRATES

E- have you tried painkillers, does it wake you up at night

Question 3

Red flags back pain

Answer 3

New onset incontinence 
Saddle anaesthesia 
Muscle weakness legs 
History of cancer 
Weight loss
Non mechanical 
Night time pain 
Violent trauma
Age <20 or 50+
Thoracic back pain 
IVDU

Question 4

Systems review

Answer 4

Trauma- history of trauma
NS- weak legs, strange sensations down legs or buttocks, problems controlling water works or bowels
Constitutional- FWARJLTF

MSK- Stiffness in joints, how long does it last, swelling (red, swollen), infections eg. UTI, STI, painful red eyes, back pain/stiffness, Rashes, mouth ulcers, dry eyes or mouth, painful cold hands that change colour, nodules, back pain, breathing difficulties, psoriasis

Question 5

Patients perspective

Answer 5

Feelings and impact on life

ICE

Question 6

Background

Answer 6

PMH- ever had back pain before, what about cancer, osteoporosis
DH
FH- osteoporosis etc.
SH

Question 7

Mechanical/non specific lower back pain

Answer 7

Absence of red flags
Clinical diagnosis
Pain varies with posture and is worse on movement
History of similar episodes
May be history of mild trauma or heavy lifting, or it’s spontaneous

Question 8

Radiculopathy (sciatica)

Answer 8

Unilateral leg pain radiating below knee to foot or toes

Leg pain may be worse than back pain

Question 9

Cauda equina

Answer 9

Urinary and faecal incontinence
Sensory numbness of buttocks and backs of thighs and weakness in legs
Caused by disc prolapse, infection, and malignancy

Question 10

Malignancy

Answer 10

Systemically unwell (weight loss) and symptoms from primary malignancy 
Constant pain not relived by rest
Night pain 
Band like pain 
History of malignancy 

Question 11

Osteoporotic vertebral fracture

Answer 11

Osteoporosis (think elderly female)

Sudden localised back pain after minimal trauma, sometimes after a sneeze

Question 12

Discitis (infection and TB)

Answer 12

Severe back pain in a systemically unwell patient with fever and night sweats
Past history of TB

Question 13

Inflammatory back pain (HLA B27 associated)

Answer 13

AS, PA, enteropathic arthritis, reactive arthritis
Young Caucasian males
Morning back stiffness lasting longer than an hour that gets better with exercise
Reduced range of movement of spine with characteristic question mark posture in the lateral stages
Patient more comfortable slightly stopped forward

Question 14

Non spinal causes of back pain

Answer 14

Dissecting aortic aneurysm- sudden onset severe tearing back pain felt between the shoulder blades
Ruptured AAA
Fibromyalgia- also generalised myalgia and arthralgia
Pancreatitis, endometriosis, renal calculus

Question 15

Investigations

Answer 15

Back exam and lower limb neuro
No further if non specific
FBC CRP ESR autoimmune screen if inflammatory
MRI and neurosurgery referral if radiculopathy
AE cauda equina

Stay active avoid prolonged bed rest, physio, analgesia (NSAIDs)