Back pain

Question 1

Differentials.

a) What would suggest mechanical cause?
b) What serious causes should be excluded?

Answer 1

a) Low back pain which varies with posture and is exacerbated by movement.
b) Serious spinal pathology, inflammatory features, and sciatica should be excluded.

Question 2

Management of simple back pain.

a) Simple

Answer 2

• Advise staying active, resuming normal activities, and returning to work as soon as possible.
• Analgesia: NSAID first-line, or codeine with or without paracetamol if an NSAID is contraindicated or not tolerated).
• If the paraspinal muscles are in spasm, a short course of diazepam can also be considered.
• Group exercise, and/or cognitive behavioural therapy, and/or physiotherapy.

Question 3

When should surgical referral be considered?

Answer 3

Refer urgently to a neurosurgeon or orthopaedic surgeon if there are:
- red flags including progressive, persistent, or severe neurological deficit.

Question 4

Spinal stenosis.

a) Most common in what region? And the second most common region?
b) Causes
c) Typical presentation (lumbar)
d) Differentials
e) Management

Answer 4

a) Lumbar spine, then cervical spine (thoracic very rare)
b) Main one - OA. Other - inflammatory arthritis (e.g. Ank Spond), Paget’s disease, acromegaly

c) - Pain in back, buttocks or legs.
- Worse on standing, walking and lumbar extension (walking downhill).
- Relieved by flexion (bending forward; usually OK cycling and walking uphill)
- Neurological symptoms: weakness, sensory disturbance, bladder/bowel dysfunction, cord syndrome

d) CES, intermittent claudication, other spinal compression (tumour, fracture, disc herniation, trauma, abscess, haematoma, etc.),

e) - Full spinal and neurological examination (+ vascular if PAD cannot be ruled out)
- Spinal MRI (alternative: CT myelography)
- Conservative: weight reduction, NSAIDs/ neuropathic drugs, physiotherapy
- If these fail - spinal decompression surgery

Question 5

Serious causes of back pain

Answer 5

• CES/ cord compression
• AAA
• Myeloma

Question 6

Cancers in the bone.

a) 5 common cancers that metastasise to bone
b) Main other cancer to consider for back pain
c) Bone primaries (rare, but more common in who?)

Answer 6

a) Breast, lung, prostate, thyroid, kidney
b) Myeloma
c) Osteosarcoma, Ewing’s sarcoma: more common in children

Question 7

Spondyloarthritis: SPINE ACHE

Answer 7

Sausage digit (dactylitis)
Psoriasis (or FHx)
Inflammatory back pain
NSAID-responsive
Enthesitis (achilles)
Arthritis
Crohn's/colitis/CRP raised
HLA-B27
Eye - anterior uveitis