Primary Care Management of Back Pain

Question 1

What do patients present to the GP with?

Answer 1

Pain = localised, lumbar, referred (e.g sciatica)
Stiffness
Loss of sleep and function (e.g walking, lifting, carrying)

Question 2

What features will the patient’s history contain?

Answer 2

Pain = type, radiates/localised
Loss of function = subjective, try to find out how it impacts patient
Trauma (recent/past) or previous surgery
Symptoms suggesting other pathology = urinary tract, GI, respiratory, systemic illness

Question 3

What are you looking for on examination of a patient?

Answer 3

Look = how the patient walks, deformity (eg scoliosis, kyphosis, scars)
Feel = spinal tenderness, paravertebral muscles
Move = flexion, extension, lateral flexion, SLR, tone, power, reflexes, sensation of legs if indicated

Question 4

What investigations can be done?

Answer 4

Usually none, ESR/PV/calcium/alkaline phosphatase, rarely x-ray, MRI

Question 5

When should an MRI be done?

Answer 5

Only if red flags present or if considering surgery (non-resolving sciatica, spinal stenosis)

Question 6

What may imaging show?

Answer 6

Loss of joint space, osteophytes, sclerosis, subarticular cysts

Question 7

What are some causes of back pain?

Answer 7

Mechanical/non-specific >90%
Tumour/metastases = 0.7%
Ankylosing spondylitis = 0.3%
Infection = 0.01%

Question 8

What are some red flag symptoms?

Answer 8

Age <20 or >50
Thoracic pain
Feeling unwell
Widespread neurological symptoms
Previous carcinoma (breast, bronchus, prostate)
Immunocompromised (HIV, steroids)
Weight loss
Structural spinal deformity

Question 9

What are some yellow flag symptoms?

Answer 9

Low mood
High levels of pain/disability
Belief that activity is harmful
Low education level
Obesity
Problem with claim/compensation
Job dissatisfaction
Light duties not available at work/heavy lifting at work

Question 10

What do patients want from their GP?

Answer 10

Cure, analgesia, explanation, reassurance, restoration of function, referral, sick line

Question 11

What are some non-pharmacological treatments?

Answer 11

Explanation, reassurance and encouraging positive mental attitudes
Physiotherapy
Osteopathy and chiropractic
Referral

Question 12

What are some pharmacological treatments?

Answer 12

Analgesics = paracetamol, co-analgesics, opiates
NSAIDs (short term)
Muscle relaxants = diazepam (short term)