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Lower back pain

 

Background

  • Most low back pain is ‘mechanical’ and self-limiting; however some back pain is sinister (i.e. caused by malignancy, osteoporotic fracture or due to spinal cord/cauda equina compression) and it is important to pick these people out.

 

Red Flag Symptoms in lower back pain

  • Patient
    • Age <20 or >55
    • Current or recent infection (especially TB, but staph and others will infect the spine)
    • Immunosuppression (infection)
    • Abdominal mass (malignancy)
  • Symptoms
    • Acute onset in elderly (think osteoporotic fracture)
    • Constant or progressive pain
    • Pain at night
    • Pain when supine (pain usually improves on lying flat in mechanical back problems)
    • Morning stiffness
    • Fever, high sweats, weight loss (malignancy)
    • Thoracic back pain
    • Bilateral or alternating symptoms
    • Neurological abnormalities (weakness, numbness)
    • Sphincter disturbance (incontinence of urine and faeces)
    • Leg ‘claudication’ (? Spinal stenosis)

 

Features of inflammatory back disease

  • Insidious onset
  • Onset at young age
  • Worse in the morning
  • Improves with exercise

 

Examination of the patient with back pain

  • Look for kyphosis/scoliosis
  • Spinal tenderness
  • Lumbar forward flexion (Schober’s test) and lateral flexion
  • Neurological examination
    • Including DRE if suspecting cauda equina
  • Straight leg raise
  • Systemic examination

 

Indications for MRI in lower back pain

  • If suspecting:
    • Cord compression
    • Cauda equina
    • Infection
    • Malignancy
    • Acute fracture
    • Inflammatory back disease

 

Treatment of lower back pain

If red flags positive:

  • Analgesia (see below)
  • MRI
    • No indication for lumbar XR unless suspicion of lumbar fracture (e.g. elderly patient with trauma, likely or known osteoporosis or long term steroids)
  • Refer to neurosurgeons.
    • Summary of indications for neurosurgical review
      • Cauda equina [bilateral or alternating root pain into lower legs, saddle anaesthesia, loss of anal tone].
      • Cord compression [bilateral pain, LMN signs at level of compression and UMN and sensory signs below, loss of anal tone]
      • Nerve root compression and mechanical symptoms not responding after 6-10 weeks
      • Progressive pain or severe neurological deficit

 If no red flags:

  • Analgesia
    • Regular paracetamol
    • NSAIDS – ibuprofen or diclofenac
      • Consider PPI cover, especially in over 65 year olds.
      • Ensure patient knows to stop PPI when NSAIDS stopped.
    • Tramadol 50mg QDS PRN
      • Generally more appropriate than codeine as these patients are often young so transient confusion with tramadol less likely.
      • Tramadol is also less constipating than codeine.
    • Gabapentin (can be given from the outset)
      • Start at 150mg at night. Titrate over a few days to 300mg TDS.
      • Can go up to 3.6g daily in severe cases.
    • If there is clear paraspinal muscle spasm (can usually feel this) then a short course of PRN low dose benzodiazepines as reasonable.
      • 2mg PRN max TDS
    • Avoid oramorph if possible
  • Education
    • Return to normal activities and gentle exercise is much better than bed rest
    • Avoid precipitants (heavy lifting, poor posture)
    • Give basic advice on posture
  • Address psycho-social issues
  • Safety net
    • Warn re red flag symptoms
    • Refer to physiotherapy if not improving

 

Click here for medical student OSCE and PACES questions about Lower back pain

Common Lower back pain exam questions for medical students, finals, OSCEs and MRCP PACES

 

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Perfect revision for medical students, finals, OSCEs and MRCP PACES

 

 

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