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Pain felt in the back. Very obvious, that one.
EpidemiologyGP. Its the single biggest UK cause of time lost from work. Around 90% of us with suffer with it at some point.
There are many different cause of back pain. The key ones to be aware of are:
- Osteoarthritis (OA)- in itself can cause back pain but may cause the following
- Infection - spinal TB
- Mass causing compression - particularly any sort of cancer, often metastatic
- Being old
- Being female
- Working in a manual job (including being a nurse)
- Being overweight
The first thing to ask about is:
Red Flag Symptoms
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.Medical Emergency - Cauda equina syndrome - sudden new incontinence, progressing motor weakness, loss of sensation round the S dermatomes and signs of bilateral nerve involvement.
- Age <20 (ankylosing spondylitis) or >55 yrs old
- Acute onset in elderly
- Constant/progressive - this can be ankylosing spondylitis or haematological malignancy
- Worse when supine
- Morning stiffness (ankylosing spondylitis)
- Fever, weight loss, night sweats (meaning so much sweat, you have to change bedding) (TB or haematological malignancy)
- Previous malignancy
- Thoracic back pain (aortic dissection)
- Bilateral/alternating symptoms
- Leg claudication (spinal stenosis)
- Current/recent infection
- Immunosuppression (e.g. steroids)
- Abdominal mass
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.
- 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.
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:
- X-ray - fracture; spondylolisthesis
- MRI - malignancy; suspected disc prolapse; spinal stenosis
- Bone mineral density - where there is suspected osteoporosis
For medical causes, the battery of tests involved will depend on the cause.
Any other tests appropriate for the specific conditions.
With normal simple back pain, it is important to keep mobile. Bed rest is not recommended.
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.
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.