Acute back pain

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  • a : Nerve root pain Nerve root pain (also known as sciatica) occurs when the sciatic nerve becomes trapped or irritated either in the lumbosacral spine or the muscles of the lower back or buttock. Patients usually experience pain in the back or buttock that radiates to the thigh and sometimes to the lower leg. Patients may also experience neurological symptoms such as tingling of the affected leg. This patient does not have sciatica because she does not have the symptoms and signs associated with the condition. b : Compression fracture of the spine This patient does not have a compression fracture of the spine because there is no pain or deformity of the spine. Patients with a compression fracture of the spine usually have a deformity of the spine and pain over the affected vertebrae. The pain often improves when the patient lies down. c : Non-specific low back pain This patient's symptoms began after straining her back so the most likely diagnosis is non-specific low back pain. This is pain that is due to dysfunction of the back such as a strain of the muscles and ligaments. d : Prolapse of the intervertebral disc It is possible for the intervertebral disc to prolapse after bending or lifting. Patients with this condition usually have a limited range of moment of the back and may find it difficult to straighten their back. Patients can also experience nerve root pain. It is unlikely that this patient has a prolapse of the intervertebral disc because she has no symptoms of nerve root pain and normal movement of her back.
  • a : Advise the patient to rest in bed for a week You should not advise the patient to rest in bed. Bed rest is less effective at reducing symptoms than staying active.1 3 You should advise this patient to stay active and try to return to her usual activities. You do not need to sign this patient off work. You should encourage patients to stay active and return to their normal activities including work if possible.1b : Request an x ray of the thoracolumbar spine You should not request an x ray in patients with non-specific low back pain.1 4 5 There is no evidence that x rays change the outcome in these patients because the pain is usually due to muscle strain and not bone disease.1c : Advise the patient to stay active You should advise this patient to stay active and try to return to her normal activities, including work if possible. You should advise her that she may have to do activities more slowly and that she should avoid twisting or lifting.
  • a : Assess the patient for yellow flags This patient takes antidepressants and has had time off work for back pain. You should assess her for yellow flags. These are psychosocial factors that can inhibit recovery from acute back pain.1 They are associated with chronic back pain, long term disability, and time off work.1 4 6 Exploring yellow flags at this stage may help you understand the patient's psychosocial problems. You may be able to offer the patient other forms of treatment such as counselling for her depression. b : Refer the patient to a psychiatrist You do not need to refer her to a psychiatrist since her symptoms of depression are stable and she is not suicidal. You should use this consultation to explore yellow flags. c : Increase the dose of antidepressants Before increasing the dose of antidepressants, you should first explore yellow flags. The patient may benefit from counselling or other therapy.
  • a : Start paracetamol and steroids and review the patient in one week The most likely diagnosis in this patient is spinal cord compression due to metastatic prostate cancer. Although steroids and paracetamol will help the patient's pain and reduce inflammation of the spinal cord you should not delay referral. You should immediately refer this patient to hospital, with a view to a magnetic resonance imaging of the spinal cord to identify if there is cord compression. The patient may need referral to the neurosurgical unit. b : Refer the patient to hospital immediately This patient has a history of prostate cancer and has presented with symptoms of spinal cord compression. A delay in treatment could result in permanent paralysis of the motor nerves. c : Arrange an urgent outpatient appointment with the neurosurgeons You should not delay referral. The most likely diagnosis in this patient is spinal cord compression. You should immediately refer the patient to hospital for assessment.
  • a : Compression fracture of the spine This patient is over 80 and has recently fractured her wrist after a minor fall. The most likely diagnosis is a compression fracture of the spine due to osteoporosis. Patients with osteoporosis can develop a compression fracture of the spine following a minor injury or sometimes from bending down. You should start analgesia and advise the patient to stay active. b : Non-specific low back pain Patients with non-specific low back pain should not have deformity of the spine and do not usually have thoracic pain. They usually have localised pain in the lower back that is often mechanical (made worse by certain movements and postures). c : Spinal cord compression due to bone metastases Patients with spinal cord compression due to bone metastases usually have a past history of cancer. It is unlikely that this patient has spinal cord compression because she does not have a history of malignancy and there are no neurological symptoms or signs.
  • a : Non-specific low back pain Patients with non-specific low back pain do not usually experience buttock pain or pain radiating down the leg. This patient has signs and symptoms that suggest nerve root pain. b : Mechanical back pain Patients with mechanical back pain experience pain that is worse with certain movements and postures. This patient has nerve root pain because he is experiencing pain in the buttock that radiates down the leg. c : Nerve root pain The most likely diagnosis is nerve root pain (also known as sciatica). The straight leg raise test is usually positive on the affected side. This is because raising the leg causes irritation of the sciatic nerve. This causes pain and sometimes numbness or tingling in the leg. d : Caudaequina syndrome Caudaequina syndrome is compression of the spinal cord below the level of the L2 vertebra. Patients with this condition usually present with neurological symptoms such as saddle anaesthesia. The condition is a neurological emergency. It is unlikely that this patient has caudaequina syndrome because he does not have any signs or symptoms associated with the condition.
  • a : Refer the patient to a physiotherapist for exercises and manipulation You should not refer the patient to a physiotherapist at this stage. You can refer patients to a physiotherapist if they have not returned to normal activities after four to six weeks.1 6 8b : Advise the patient that it may take two months for his symptoms to settle You should advise patients with nerve root pain that it may take up to two months for their symptoms to settle.4c : Refer the patient to the neurosurgeons for spinal surgery You do not need to refer this patient to the neurosurgeons because he does not have symptoms that warrant surgery. You should make an urgent referral if the patient's symptoms worsen or progress. For example, if they develop foot drop. d : Refer the patient to back school to educate him about back care You do not need to refer patients with nerve root pain to a back school. Back schools are usually run in the workplace.9 They educate patients about back care, how to avoid back pain, and exercises that can strengthen the back. A recent Cochrane review showed that back schools in an occupational setting can help patients with chronic low back pain.9
  • a : Amitriptyline This patient is likely to have muscle spasm and non-specific low back pain. There is no evidence for the use of drugs such as amitriptyline in patients with acute non-specific back pain. b : Gabapentin You should not start gabapentin in patients with acute non-specific back pain. One systematic review found gabapentin an effective treatment in patients with nerve root pain but there are no meta-analyses or large studies to support this.14c : Morphine You should not start strong opioid drugs such as morphine in patients with non-specific low back pain. You can give low dose opioid drugs such as co-codamol to these patients if paracetamol and non-steroidal anti-inflammatory drugs are inadequate.1 4d : Diazepam You can give a short course (maximum one week) of diazepam to patients with muscle spasm.1 4 15 You can also give a short course of diazepam to patients who are taking a combination of non-steroidal anti-inflammatory drugs, paracetamol, and a mild opiate but are still experiencing pain.
  • a : Ankylosing spondylitis This patient has a long history of back stiffness that is worse in the mornings. The positive Schober's test, raised C reactive protein and erythrocyte sedimentation rate are suggestive of ankylosing spondylitis. This is an inflammatory condition that usually affects the spine and sacroiliac joints. Patients with this condition usually experience stiffness and reduced mobility of the back that gradually worsens. b : Non-specific back pain Patients with non-specific back pain do not usually experience morning stiffness of the back. They do experience localised pain in the back that usually settles within two weeks with analgesia and mobilisation. c : Mechanical back pain Patients with mechanical back pain experience pain with certain movements such as twisting. d : Rheumatoid arthritis It is unlikely that this patient has rheumatoid arthritis. Patients with this condition usually present with symptoms of swelling and pain in the small joints of the hands and feet.
  • Acute back pain

    1. 1. Acute back pain<br />
    2. 2. What you should know<br />The common causes<br />How to assess patients and when to refer them<br />The red & yellow flags<br />How to manage patients with acute back pain.<br />
    3. 3. Why back pain is important<br />Common presentation<br />Back pain affects up to ⅓ of the adult population<br />2nd most common cause of long-term absence from work<br />If you miss an episode of spinal pathology, itcan result in permanent damage to the motor nerves.<br />
    4. 4. Question 1<br />You see a 45 year old woman who has been experiencing pain in her right lower back for the last two days. The pain began after she reached to get something from a cupboard.<br />There is no radiation of the pain and she has no neurological symptoms. There is no vertebral tenderness and no deformity of the spine. There is tenderness of the muscles of her lower back on the right. The patient has normal back movements but her movement forward is limited by pain. The straight leg raise is normal and there are no neurological signs.<br />What do you think is the most likely diagnosis?<br />Nerve root pain<br />Compression fracture of the spine<br />Non-specific low back pain<br />Prolapse of the intervertebral disc <br />
    5. 5. Classifications<br />Acute low back pain - pain <6 weeks<br />Sub acute low back pain - pain 6-12 weeks<br />Chronic low back pain - pain >12 weeks<br />Serious spinal pathology <br />Infection, malignancy, fracture, and inflammatory causes e.g. ankylosing spondylitis<br />Nerve root pain <br />The sciatic nerve becomes trapped or irritated in the lumbosacral spine or the muscles of the lower back or buttock<br />It may take 2 months for symptoms to resolve<br />Non-specific low back pain <br />Often triggered by a minor sprain or strain of the back<br />May be mechanical - worsened by certain movement or postures<br />Pain usually improves within two weeks.<br />
    6. 6. Question 2<br />You make a diagnosis of non-specific low back pain. You explain the problem to the patient and reassure her that her symptoms are likely to improve within two weeks. She tells you that she works in an office and is able to take regular breaks and walk around. The patient takes paracetamol regularly for arthritis in her knees. You start ibuprofen in addition to the paracetamol.<br />What else should you do?<br />a. Advise the patient to rest in bed for a week <br />b. Request an x ray of the thoracolumbar spine<br />c. Advise the patient to stay active <br />
    7. 7. History & examintion<br />Rule out serious pathology by asking about red flags<br />Ask about nerve root pain<br />Examine all patients (usually a brief examination is sufficient)<br />Examine other joints close to the back such as the hip joint for pain <br />Pain can be referred from the hip joint to the back.<br />
    8. 8. Back examination<br />Inspection of the back and spine<br />Palpation of the vertebral column, paraspinal muscles, and gluteal muscles<br />Testing for range of movement of the back<br />Examination of the hips<br />Straight leg raise and sciatic stretch test<br />Tone, power, reflexes, and sensation of the lower limbs.<br />
    9. 9. Question 3<br />You see a 35 year old woman with acute back pain that you diagnose as non-specific low back pain. You note that she has been signed off work by a doctor three times in the last six months for back pain. She also takes antidepressant tablets for depression. Her symptoms of depression are stable and she is not suicidal.<br />What else should you do in this consultation?<br />a : Assess the patient for yellow flags<br />b : Refer the patient to a psychiatrist<br />c : Increase the dose of antidepressants <br />
    10. 10. Yellow Flags<br />Psychosocial barriers that inhibit recovery from back pain<br />An inappropriate perception of back pain, e.g. <br />belief that back pain is harmful and disabling<br />belief that passive activity such as bed rest is better than staying active<br />Lack of support at home and social isolation<br />Mental health problems such as depression, anxiety and stress<br />Problems at work e.g. bullying, job dissatisfaction<br />Claims for compensation and benefits.<br />
    11. 11. Treatment in primary care<br />Aims<br />Relieve pain<br />Improve function<br />Prevent recurrence of pain<br />Prevent chronic pain<br />Options<br />Paracetamol, ibuprofen, co-codamol, diazepam<br />Analgesic rubs<br />Self-help: books, schools, exercises<br />Sign off work<br />
    12. 12. Question 4<br />You see an 80 year old man who was diagnosed with prostate cancer six months ago. He has had pain in his upper back that has worsened over the last week. For the last two days he has found it difficult to walk. On examination, he is tender over the mid thoracic spine. There is reduced power and increased tone in both legs. His plantar reflexes are up going.<br />What should you do?<br />a : Start paracetamol and steroids and review in 1week <br />b : Refer the patient to hospital immediately <br />c : Arrange an urgent outpatient appointment with the neurosurgeons <br />
    13. 13. Spinal cord compression<br />The thoracic vertebrae are a common site for compression of the spinal cord.<br />The general symptoms of spinal cord compression include:<br />Weakness and abnormal sensation of the lower limbs<br />Pain over the vertebrae<br />Urinary retention<br />Faecal incontinence.<br />The spinal cord ends at the level of the L1 and L2 vertebrae. Compression above this level causes upper motor neurone signs. <br />
    14. 14. Caudaequina syndrome<br />Compression of the spinal cord below the level of L2 vertebra.<br />Causes lower motor neurone signs:<br />Reduced tone in the limbs<br />Absent or reduced reflexes<br />Plantar reflexes that are down going.<br />You should suspect a diagnosis of caudaequina syndrome in patients with:<br />Gait disturbance and limb weakness - this is due to lower motor nerve compression<br />Urinary retention or incontinence<br />Faecal incontinence<br />Saddle anaesthesia - this is numbness of the groin, buttocks, and back of the thighs.<br />This is an emergency – refer immediately to hospital!<br />
    15. 15. Red Flags<br />Age <20 or >55 years<br />Recent history of trauma<br />Constant progressive pain - this includes pain that is not associated with movement and not relieved by lying down<br />Thoracic pain<br />Past history of malignancy<br />Recurrent or prolonged use of corticosteroids<br />Immunosuppression/HIV<br />Substance misuse<br />Being systemically unwell<br />Unexplained weight loss<br />Neurological symptoms such as weakness of the limbs<br />Structural deformity of the spine.<br />
    16. 16. Question 5<br />On a home visit, you see an 85 year old woman. Yesterday she slipped on a wet floor and landed on her bottom. Since then she has had severe pain in the middle of her back. She is able to walk but tells you the pain is better when she lies down. The pain is not radiating and she has no neurological symptoms. She is tender over the T10 vertebra. There are no neurological signs. On reviewing her records, you note that she fractured her wrist after tripping over a kerb a year ago.<br />What’s your diagnosis?<br />a : Compression fracture of the spine<br />b : Non-specific low back pain <br />c : Spinal cord compression due to bone metastases<br />
    17. 17. Compression #<br />Patients with a compression fracture of the spine due to osteoporosis sometimes find that the pain is better when they lie down.<br />In patients with osteoporosis, if there are no contraindications, you should start calcium supplements and a bisphosphonate, such as alendronate.<br />This can improve bone density and reduce the risk of further fractures.<br />
    18. 18. Question 6<br />You see a 30 year old man who developed acute pain in the left buttock two days ago. The pain started when he was stretching before football. The pain has now moved down his leg and he also has some tingling in L foot. There are no red flags. On examination, there is tenderness of the Lbuttock. The straight leg raise test is positive on the Lside. The tone, power, reflexes, and sensation are normal in the lower limbs.<br />What is the most likely diagnosis? <br />a: Non-specific back pain b: Mechanical back pain<br />c: Nerve root pain d :Caudaequina syndrome<br />
    19. 19. Question 7<br />You make a diagnosis of nerve root pain. You explain the diagnosis and start paracetamol and ibuprofen. You advise the patient to stay active and gradually return to normal activities.<br />What else should you do?<br />a : Refer the patient to a physiotherapist for exercises and manipulation<br />b : Advise the patient that it may take two months for his symptoms to settle <br />c : Refer the patient to the neurosurgeons for spinal surgery <br />d : Refer the patient to back school to educate him about back care <br />
    20. 20. Question 8<br />You see a 50 year old woman who has been experiencing pain in her right lower back for the last four days. The pain is not radiating and there are no red flags. On examination, there is no deformity or tenderness of the vertebrae. You notice that the muscles of the right lower back are in spasm. There are no neurological signs. She takes co-codamol and diclofenac for arthritis in her knees but they are not helping her back pain.<br />What else would you start?<br />a : Amitriptyline b : Gabapentin <br />c : Morphine d : Diazepam <br />
    21. 21. Question 9<br />A 25 year old man has been experiencing back stiffness for the last six months. The back stiffness is worse in the morning but improves through the day. For the last week his back has been more stiff than usual and it takes him about an hour to loosen up. The pain does not radiate and there are no neurological symptoms. On examination, he has tenderness over the lumbar spine. The range of movement of the spine is limited. Schober's test is positive.<br />What is the most likely diagnosis?<br />a: Ankylosingspondylitis b: Non-specific back pain<br />c: Mechanical back pain d: Rheumatoid arthritis <br />
    22. 22. Question 10<br />You make a diagnosis of ankylosing spondylitis. What should you do next?<br />a : Refer the patient immediately to hospital for a CT scan of the spine <br />b : Make an urgent outpatient referral to the orthopaedic team <br />c : Make an urgent outpatient referral to the rheumatology team<br />
    23. 23. Key points<br />The most common cause of acute back pain is non-specific back pain<br />Most episodes of non-specific back pain resolve within two weeks<br />Staying active is crucial in back pain management<br />A thorough examination can reveal important findings and is very reassuring for the patient<br />Patients who present with red flags can develop permanent damage to motor nerves<br />Yellow flags are psychological factors that can inhibit recovery from back pain<br />

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