Aetiology
- Most back pain is innocent and self-limiting
Risk factors for simple back pain
- Previous back pain
- Heavy lifting/frequent bending
- Repetitive work with exposure to vibration
Investigations
Examination
- General appearance
- Vital signs
- Back examination
- Gait
- Look - from side and back
- Feel - SPs, steps, SI joints
- Move - flexion, extension, lateral bending, rotation
- Other tests: SLR, muscle strength, sensation, deep tendon reflexes
When to investigate - red flags
General
- Failure to improve after 4-6 weeks of conservative therapy
- Unrelenting night pain or pain at rest
- Progressive motor or sensory deficit
Cancer
- Age > 50 years
- Unintended weight loss
- History of cancer
- Pain at night and in recumberncy
Infection
- Fever/chills
- Recent infection
- Immunosuppression
- IV drug use
- Dental status
- Foreign travel
Radiology
- X-ray - not used routinely
- Young men - SI joint to exclude anklysing spondylitis
- Elderly - to exclude vertebral collapse, other fractures, malignancy
- CT - limited application in acute LPB without red flags
- Good for bony pathology, foreign implants, spinal fusion planning
- MRI - provides details of soft tissues
- Bone scan - increased bone scan, metastases, tumours, osteoid osteoma
- PET/SPECT - increased uptake in high turnover areas
Lab
- Indicated if red flags present
- FBC, U+Es, inflammatory markers
- Malignany e.g. PSA, acid phosphatase
- Infection
- Metabolic causes e.g. alk phos, Ca2+, HLAB-27
Management of simple back pain
Non-pharmacological
- Explanation and re-assurance
- Advice on activity and exercise
Pharmacological
- WHO pain ladder - simple analgesics → opiates for severe pain → injections
Complementary and alternative medicine
- Physiotherapy
- Acupuncture, chiropractor, osteopath, massages
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