Back pain

Question 1

A 40 year old man develops acute back pain after heavy lifting three weeks ago. He now presents with persistent low back pain, sciatica and weakness of ankle dorsiflexion. He asks about whether he should have spinal manipulation. What would you advise him?

Answer 1

Impression
Acute back pain, likely lumbosacral radiculopathy related to a lumbar intervertebral disc herniation or spondylosis causing compression of spinal roots leading to his new neurological symptoms. Likely L5 disc given dorsiflexion of big toe and ankle weakness.

Other DDx to consider

• Degenerative (unlikely given age)
• infective: discitis,
• Neoplasia (unlikely given age)

Complications to consider

• Spinal cord compression
• cauda equina (unlikely in absence of bladder/bowel sx)
• radiculopathy

Goals

• Conduct thorough Hx/Ex/Ix to characterise sx, rule out red flags
• Likely trial of conservative management in setting of no significant risk factors +/- simple analgesia, provide patient education about risks and evidence regarding efficacy of spinal manipulation.

Question 2

Back pain - History

Answer 2

History

• sx: pain (SOCRATES), bilateral vs unilateral
• REDS: TUNA FISH (trauma, unexplained weight loss, neuro deficits, age>55, fever, immunocompromised, steroids, Hx of cancer/TB/HIV.
• psychosocial hx: level of function, work, as about ?compensation
• PMHx, PSHx, meds, allergies, etc

Question 3

Back pain - Examination

Answer 3

Examination

• General obs + vitals
• MSK spine exam: mobility,
• LL neuro exam: motor/sensory deficits,
• Abdo: DRE and anal reflexes for effects on sphincter

Question 4

Back pain - Investigations

Answer 4

Investigations
Are often not required. Radiological findings are poorly correlated with lower back pain symptoms.

Key

• Lumbar spine X-Ray: malignancy, degeneration, spondylosis
• MRI back (X-Ray is a waste of time)

Given this man does have some red flags for new onset back pain, I would proceed initially with basic imaging to confirm provisional diagnosis.

Question 5

Back pain - Management

Answer 5

Management
Start with conservative management for 6 weeks unless so bad they can’t function or new onset motor sx in 24 hours.

non-pharmacological

• patient education: most have acute course which resolves in time. explain nature of pain, lack of need for investigation, clarify any of patients misconceptions
• refer to physio for core muscle strengthening and graded exercise programs for pain.
• safe lifting procedures,
• weight loss, maintain physical activity
• relaxation/distraction techniques

Advice re spinal manipulation

• limited benefit, no real evidence
• risks of making the injury worse
• avoid neck manipulations
• if going, ensure a licensed and experienced provider

Pharmacological

• avoid opioids
• start simple analgesia; NSAIDs, paracetamol

Surgical (if severe)

• microdiscectomy
• laminectomy