Low back pain

Question 1

Differential diagnosis

Answer 1

Mechanical low back pain
Cauda equina
Malignancy

Infection (e.g. discitis, osteomyelitis)

Sciatica

Renal (colic /
pyelonephritis)

Inflammatory back pain (HLAB27 - AnkSpond, psoriatic arthritis, reactive arthritis)

Osteoporotic crush fracture

Question 2

Questions to ask in HPC

Answer 2

Recent heavy lifting or trauma?

Associated symptoms - - stiffness, reduced range of movement,

• any urinary/faecal incontinence or loss of sensation in saddle region,
• systemic cancer symptoms,
• fever, malaise, warmth over affected area

Any pain/pins and needles into your bottom and down the back of your legs?

Any haematuria, dysuria? (to rule out renal causes)

Question 3

Questions to ask in PMH

Answer 3

History of back problems
History of spinal surgery
Any history of malignancy?
Other PMH

Question 4

FH questions

Answer 4

Back or joint problems

Cancer

Question 5

SH questions

Answer 5

Occupation - is there a risk of back injury
Living arrangements
Alcohol and smoking

Question 6

Examinations

Answer 6

Obs - HR, RR, BP, temp
Overlying skin changes
Gait
Spine - ROM, focal tenderness on palpation
Neurological examination

SLR - for sciatic pain
PR exam if suspect C.Equina

Question 7

Investigations

Answer 7

Only needed if suspect cause is not mechanical back pain

Bloods - FBC, CRP, ESR and cultures
MSU dipstick and culture if query renal related

Question 8

Management of mechanical back pain

Answer 8

Leaflet
Self-management - continue to exercise lightly, avoid heavy lifting, avoid immobility (bed rest), wear trainers/supportive shoes), hot water bottle, heat rubs

Work - avoid heavy lifting, PC at eye line

Pharmacy - NSAIDs (+PPI) and paracetamol, heat rub or tape to support back

Prescribe - if the person has muscle spasm, offer low dose diazepam 2mg up to TDS for up to 5 days. Amitriptyline can be used for chronic pain

Also consider physiotherapy, acupuncture