2. Case 1
• A 35 years old male presented with severe pain in his lower
back after bending down to pick up a heavy weight.
• No radiation of the pain to the lower limbs
• PH: Nil
• O/E:
– stands with increased lordosis and reduced forward flexion,
walking is painful
– tender over L5 and paravertebral muscles
– No neurological S/S
• What is the diagnosis?
• How would you manage this patient?
3. Case 2
• A 37 years old male presented with severe pain in his lower back
after bending down to pick up a heavy weight.
• The pain is radiating down the back of his left leg as far as the ankle
• PH: Nil
• O/E:
– Walks with pain
– ↓ back movements especially the forward flexion
– The muscle power was difficult to assess because of the pain
– Normal ankle dorsiflexion (bilaterally) but weak left ankle planter flexion
and big toe flexion
– Altered sensation over the lateral side of the left foot
– No other neurological S/S
• What is the diagnosis?
• How would you manage this patient?
5. Movements generated by myotomes of the lower
limb
(Drake R, Vogl W, Mitchell A. Gray's anatomy for
students. Churchill Livingstone, Edinburgh; 2004)
6. Movement Innervation
Hip flexion L1 L2
Knee extension L3 L4
Knee flexion L5 S1 S2
Hindfoot inversion L4
Great toe dorsiflexion L5
Ankle plantarflexion S1 S2
7. Back pain
• Is the leading cause of occupational
disability in the world
• The most common cause of missing work
days
• 50 - 80%
• With aging population and sedentary live
this situation is unlikely to change
8. Aim
To provide an evidence based overview of
low back pain to the primary health carer
9. Objectives
By the end of this presentation you should
be confident in managing patients with back
pain in the ED.
10. Common causes of low back pain
• Mechanical (80 – 90%)
• Neurogenic (5 – 15%)
• Non-mechanical spinal conditions (1 – 2%)
• Referred visceral pain (1 – 2%)
• Other (2 -4 %)
16. Classification by Edlow 2015
• Simple causes
– Muscular & ligamentous strains
– Isolated sciatica (Posterolateral disc herniation)
– Spinal stenosis
• Serious causes
– Cancer related
– Infection related
– Spinal epidural haematoma
– Central disc herniation causing cauda equina syndrome
• Non-spine related causes
17. Management of acute low back pain in ED
• Rule out the serious causes
• Pain management
18. Red flags
• Cauda equina Syndrome
• Spine fractures
• Malignancy or infection
19. Red flag symptoms indication possible
serious spinal pathology.
Red flag symptoms are:
•Onset at age <20 or >55
•Non-mechanical pain (i.e. unrelated to
time or activity), especially if constant and
worsening, and pain at night
•Thoracic pain
•Previous history of carcinoma, steroids or
HIV infection
•Fever, night sweats, weight loss
•Widespread neurological symptoms
especially sphincter disturbance
•Structural spinal deformity
20. Red Flags – Cauda equina syndrome
• Saddle anesthesia or paresthesia
• Recent onset of bladder dysfunction
• Recent onset of faecal incontinence
• Perianal/perineal sensory loss
• Unexplained laxity of the anal sphincter
• Severe or progressive neurological deficits in the
lower limbs
21. Red Flags – spinal fracture
– Sudden onset of severe central pain in the spine
which is relieved by lying down.
– Major trauma such as a road accident or fall from a
height.
– Minor trauma, or even just strenuous lifting, in people
with osteoporosis.
– Structural deformity of the spine (such as a step from
one vertebra to an adjacent vertebra).
– Point tenderness over the vertebral body
22. Red flags – Malignancy or infection
• Pain that remains when lying down, aching night-time pain that
disturbs sleep, and thoracic pain could also be caused by an aortic
aneurysm.
• Onset in people aged above 50 years or below 20 years.
• History of cancer.
• Constitutional symptoms, such as fever, chills, or unexplained
weight loss.
• Recent bacterial infection - eg, urinary tract infection.
• Intravenous drug misuse.
• Immune suppression.
• Structural deformity of the spine (such as scoliosis).
• Point tenderness over the vertebral body.
23. Investigations
• No investigations are required in majority
of cases
• Limited role of X ray in non traumatic low
back pain
• Lab investigations if red flags are present
24. The Biomarkers
• Routine lab testing is not useful
• WBCs
– elevated only in 2/3 of patients with epidural abscess
• CRP & ESR
– Highly sensitive but non specific
– ESR & CRP not recommended for patients with no red flags
26. So the evidences……?
• First line agents (Paracetamol & NSAID)
– Paracetamol is ineffective
Machado 2015
Australian Institute of health & welfare, 2010
– NSAID
No difference over placebo when added to
paracetamol
Machado 2017
27. So the evidences……?
• Steroids
No benefit
• In herniated disc (Goldberg 2015)
• In undifferentiated patients (Eskin 2014)
• Muscle relaxants & Opiates
No benefit (Swaminathan 2017)
• Cyclobenzaparine & Naproxen
No benefit (Friedman 2015)
• Opiates & Paracetamol
No benefit in pain control or functional outcome at 1/52 & 3/12
(Friedman 2015)
28. The real Management
• Discussing expectations
– Likely to have pain for 6/52 (Menezes Costa 2012)
– Up to 60% will have pain and decrease
function after one year
• Educate your patient
• Medications
• Discharge instructions: verbal & leaflet
Key recommendations (NICE November 2016)
1. Paracetamol alone is no longer recommended as the primary option. Therapy should instead be initiated with NSAIDs such as ibuprofen or aspirin.
2. Oral NSAIDs should be used ‘at the lowest effective dose for the shortest possible period of time’.
3. Weak opioids like codeine should be considered for acute back pain only when NSAIDs are contraindicated or fail to work.
4. Imaging in a non-specialist setting should not be offered routinely.
5. A combined physical and psychological programme should be considered in patients not responding to previous therapies or those with psychosocial obstacles to recovery.
6. Patients should be encouraged to continue with regular activities as far as possible.
7. NICE recommends considering a group exercise programme as a part of the treatment regimen.
8. Massage and manipulation to be used only in conjunction to exercise.
9. Acupuncture, electrotherapies, and spinal injections are not recommended for managing low back pain; however, in patients with severe acute and severe sciatica, epidural injections of local anaesthetic and steroid can be considered.
10. Epidural injections should not be used for neurogenic claudication in patients with central spinal canal stenosis.
11. Patients with chronic back pain (moderate or severe localised back pain), not responding to non-surgical treatment and with pain originating from structures supplied by the medial branch nerve should be referred for assessment for radiofrequency denervation.
