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Back pain

This is a woman with back pain.

Definition

Pain felt in the back. Very obvious, that one.

Epidemiology

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You will see this all the time in GP. Its the single biggest UK cause of time lost from work. Around 90% of us with suffer with it at some point.

Differential Diagnosis

There are many different cause of back pain. The key ones to be aware of are:

  • Mechanical
    • Idiopathic - for around 80%, the cause of pain is unknown!
    • Fracture - this can be due to osteoporosis
    • Disc prolapse - commonly known as "a slipped disc"
    • Skeletal muscle - either pulled or in spasm
  • Osteoarthritis (OA)- in itself can cause back pain but may cause the following
    • Spinal stenosis - a narrowed spinal canal due to facet joint OA
    • Spondylolisthesis - displacement (usu. forward) of one lumbar vertebra on another; commonly caused by posterior facet joint OA
  • Infection - spinal TB
  • Obesity
  • Mass causing compression - particularly any sort of cancer, often metastatic

Less common are: pregnancy; gynaecological problems in women, such as pelvic inflammatory disease; stress; viral infections; bone disorders; bladder and kidney infections.

Risk Factors

  • Being old
  • Being female
  • Working in a manual job (including being a nurse)
  • Being overweight

Clinical Features

The first thing to ask about is:

Red Flag Symptoms

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These are the ones that if you see you go AAAARGH and immediately refer them to a big scary consultant immediately. Unless otherwise stated, this is probably due to it being a sign of cancer.

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Medical Emergency - Cauda equina syndrome - sudden new incontinence, progressing motor weakness, loss of sensation round the S dermatomes and signs of bilateral nerve involvement.

Serious symptoms

The rest are important to catch and refer, but not life threatening: They seem to be getting a slowly worsening neurological problem OR You suspect an underlying inflammation, such as ankylosing spondylitis - young man, chronic back pain and stiffening. Osteoporosis is also something that needs to be considered.

Further diagnosis

  • Fracture - history of trauma. Essentially, you diagnoses a fracture by doing an appropriate X-ray
  • Disc prolapse - usually sudden-onset back pain after coughing, sneezing or some heavy manual work. This usually follows a few days of general back discomfort. It either causes lumbago (low back pain) or sciatica (neurological pain radiating to the buttocks and leg).
  • Skeletal muscle - spasm is sudden-onset but goes away eventually. Can be incredibly painful.
  • Osteoarthritis - degenerative change that may result in
    • Spinal stenosis - pain, aching and heaviness in legs worse on walking; pain on extension; negative straight-leg raising; few neurological features
    • Spondylolisthesis - onset of pain can occur with or without sciatica. Usually in adolescence.

Investigations

It very much depends on their symptoms. Your average patient, you probably wouldn't investigate at all, then others you would send for every test going:

For medical causes, the battery of tests involved will depend on the cause.

Any other tests appropriate for the specific conditions.

Management

With normal simple back pain, it is important to keep mobile. Bed rest is not recommended.

Medication

The vast majority of back pain is managed with paracetamol or gentle NSAIDs like ibuprofen. The next step after this is a stronger NSAID such as Diclofenac or a weak opiod such as Co-codamol.

Alternative Therapies

Commonly used are osteopaths and chiropracters. Both are fairly similar, in that they use techniques of joint manipulation to relieve pain and improve mobility and symptoms. Generally an osteopath is more holistic, looking at the whole body to solve the joint problems, whereas a chiropracter is more into the joints themselves.

Prognosis

Many patients suffer from back pain for a long time. Some people suffer more acutely. However, unless its one of the red flags above, you will almost certainly live.