Back Pain

Question 1

Red flags for lower back pain

Answer 1

-Age < 20 years or > 50 years
-History of previous malignancy
-Night pain
-History of trauma
-Systemically unwell e.g. weight loss, fever

Question 2

Causes of lower back pain

Answer 2

-Spinal stenosis
-Ankylosing spondyloarthritis
-Peripheral arterial disease

Question 3

Overview of spinal stenosis

Answer 3

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

Question 4

Overview of ankylosing spondyloarthritis

Answer 4

Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)

Question 5

Overview of peripheral arterial disease in back pain

Answer 5

Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases

Question 6

Investigation of lower back pain

Answer 6

-Lumbar spine x-ray should not be offered
-MRI
=should only be offered to patients with non-specific back pain ‘only if the result is likely to change management’ and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected
=it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures

Question 7

Management of lower back pain

Answer 7

-Advice to people with low back pain
=try to encourage self-management
=stay physically active and exercise

-Analgesia
=NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
=proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
=NICE guidelines on neuropathic pain should be followed for patients with sciatica

-Other possible treatments
=exercise programme: ‘Consider a group exercise programme (biomechanical, aerobic, mindbody or a combination of approaches) within the NHS for people ‘
=manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) ‘but only as part of a treatment package including exercise, with or without psychological therapy.’
=radiofrequency denervation
=epidural injections of local anaesthetic and steroid for acute and severe sciatica