Common Histories - Back Pain

Question 1

Presenting complaint

-key questions

Answer 1

SOCRATES
Site - can you point to where the pain is
Spine - fracture, arthritis?
Paraspinal - muscle spasm, sprain
Lateral
-renal - pyelonephritis, renal colic
-pleuritic - PE, pneumonia
-hip - arthiritis
Between scapulas - spinal fracture, aortic aneurysm, MI

Onset

• sudden/gradual
• when did it start
• how long has this gone on for

Character - can you describe the pain
Burning - neuropathic (nerve root compression)
Tearing - dissection
Sharp - fracture, muscle spasm, PE
Present at rest and night - inflammatory, malignancy

Radiation - does the pain move anywhere
Legs, bottom - sciatica
Limbs - radiculopathy from nerve root compression
Loin => groin - renal colic
Chest - MI, AA
Epigastrium - peptic ulcer, pancreatitis
Abdo - AAA

Associated symptoms

Time course

Exacerbating - walking, coughing, lifting
Relieving - analgesia, muscle relaxants, lying down

Severity

Question 2

Systemic enquiry

-key questions to ask

Answer 2

Systemic

• fevers - UTI, pyelonephritis, pneumonia
• fatigue, weight change - malignancy

Neuro

• motor, sensory changes - nerve root, spinal cord compression
• urinary retention, incontinence - cauda equina

GU
-hematuria - back trauma, UTI, kidney cancer

Cardioresp

• chest pain - dissection, PE
• SOB, cough - pneumonia

MSK

• early morning stiffness - inflammatory arthritis
• trauma

Question 3

Past medical, drug, family history

• key questions to ask
• relevant medical conditions that relate to back pain

Answer 3

Any other problems with back pain in the past
-past investigations, diagnoses

Any other medical conditions
Current medications

Past surgeries, procedures

Relevant medical conditions that relate to back pain
Past back problems
Osteoporosis
Recent trauma
Scoliosis
Malignancy
Cardiovascular disease - MI, AA
Recent infections

Medications linked with back pain

• paracetamol, NSAIDs, opioids
• BZ, pregabalin
• CS => increased fracture risk

FHx of

• back problems
• cancer

Question 4

Social history

-key questions

Answer 4

Living

• who’s with you at home
• any dependents
• support of carers
• ability to carry out day to day tasks

Occupation

• in work?
• impact on work

Substances

• alcohol - osteoporosis, trauma
• smoking - malignancy, osteoporosis, fractures
• recdrugs

Question 5

Cauda equina

• risk factors
• core features
• investigations
• management

Answer 5

Risk factors

• age
• spinal injury

Core features
Severe, bilateral leg weakness, tingling
Recent onset urinary, fecal incontinence
Saddle anaesthesia

Investigations
Spine MRI

Management
Immediate - dexmeth
Definitive - surgical decompression, address underlying cause

Question 6

Spinal fracture

• risk factors
• core features
• investigations
• management

Answer 6

Risk factors

• major trauma - RTC, fall from height
• minor trauma + osteoporosis/CS use

Core features
Sudden onset severe central pain, relieved by lying down

Investigations
Bone profile - if suspecting osteoporosis
Spine Xray, CT, MRI - assess for fractures, soft tissue damage

Management
Analgesia - paracetamol/NSAIDs, codeine, tramadol if severe pain
Spinal brace - restrict movement
Surgery if needed

Question 7

Spinal cancer/mets

• risk factors
• core features
• investigations
• management

Answer 7

Risk factors
-50+, past Hx of cancer (breast, lung, GI, prostate, renal)

Core features
Gradual onset of symptoms
Severe unremitting pain, keeps patient up at night
Localised spinal tenderness
Cancer red flag signs

Investigations
Spine Xray
Definitive - biopsy
Staging - CAP MRI, PET scan

Management
Surgery
Chemo, radio

Question 8

Spinal infection

• risk factors
• core features
• investigations
• management

Answer 8

Risk factors

• increased age
• IC, IVDU, HIV, DM
• recent infection

Core features
Fever, weight loss, lost appetite, night pain
Swelling, warmth around site

Investigations
Xray, MRI spine - locate site of infection
FBC, CRP - infection
Blood cultures - causative organism

Management
Supportive - analgesia, spinal brace
Definitive - ABx
Surgery if ABx not enough

Question 9

Multiple myeloma

• risk factors
• core features
• investigations
• management

Answer 9

Risk factors

• older age
• FHx of myeloma

Core features
Systemically unwell - weight loss, anorexia, fatigue
Dull persistent bone pain worse on mv
Anemia - SOB, fatigue
Freq infections
Freq bruising, bleeding
Kidney involvement - fluid retention, 

Investigations
Bloods - BM failure (low Hb, WCC, Plt), light chains, paraproteins
Imaging - Full body Xray, CT - for bone damage
Definitive - bone marrow biopsy

Management
Chemotherapy
Stem cell transplants

Question 10

Sciatica

• risk factors
• core features
• investigations
• management

Answer 10

Risk factors
Increased age
Large body habitus
Frequent twisting of body
Prolonged sitting

Core features
Pain that radiates from lower back to bottom, legs
Unilateral
Pain can be sharp, burning, electrical
Worse on cough, sneeze, prolonged sitting
Numbness, tingling, weakness in affected leg

Investigations
Spine exam - gait, inspect, palpate spine and muscles, active and passive lumbar spine flexion, extension, lateral flexion, rotation, SLR test
LL neuro exam - motor and sensory signs in distribution of sciatic nerve

Management
Recovery within 4-6wks
Gentle movement, stretches
Simple analgesia
Any signs of cauda equina => A&E