A 65-year-old woman presented with lower back pain radiating to the front for one week, exacerbated by movement and relieved by rest. Examination found tenderness over the lower thoracic spine with reduced movement. Tests showed osteoporosis, and x-ray revealed a compression fracture at T12, consistent with osteoporotic vertebral fracture. She was diagnosed with osteoporosis and a compression fracture, and prescribed pain medication, bisphosphonates, calcium, and vitamin D supplementation along with exercise and fall precautions.

1. SBCE
Back Pain
11.02.2021

2. Back Pain
Lead in Case Scenario: (Chief Complaint)
A 65-year-old woman, presents with back pain for 1 week.
Cause?
2

3. Back Pain: Cause?
Lead in Case Scenario: (Chief Complaint)
A 65-year-old woman, presents with back pain for 1 week.
Cause?
1) Trauma
2) Osteoporosis with CVF
3) Prolapse Intervertebral disc
4) Degenerative spine disease (OA)
5) TB Spine
6) Spine metastasis (from lungs, breast, colon, lymphoma)
7) Renal colic due to ureteric stones
3

4. Back Pain: Details of back pain
• Site:
• Lower back, radiating to the front (not to thighs)
• Pain elsewhere? (no Hx of pain in neck, hands and hips)
• Onset/Duration: 1 week
Triggers? (No Hx injury, fall, lifting a heavy weight)
• Character: sharp pain
• Radiation:
• Associated Symptoms:
• Timing: constant pain
• Exacerbating factor: worse on turning in bed, coughing, sneezing, standing, walking)
Relieving factors: partially relieved with paracetamol, less painful while lying on back
• Severity: pain score 7/10

5. Back Pain: Associated Symptoms
• Symptoms due to S/C compression
• Symptoms of primary malignancy, TB
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6. TB, Malignancy (lungs, breast, bowel, lymphoma):
 Constitutional symptoms
 TB/Lung cancer: SOB, chest pain, cough, haemoptysis
 Bowel cancer: change in bowel habit, bleeding PR
Ureteric stones:
 Haematuria, UTI symptoms
Spinal cord compression:
Motor: Leg weakness
Sensory: loss of sensation
Bowel/Bladder: constipation, retention of urine
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Back Pain: Associated Symptoms

7. 7
Back Pain: PMH, PSH, DH, FH, SH, System Review
• PMH: No Hx of cancer, TB, arthritis
• Obs:&Gynae: Menopause at 49, No Hx Hysterectomy
• PSH: None
• Drug Hx: No Hx of corticosteroids, HRT, traditional medicine
• Family Hx:
• No Hx of cancer,
• Hx of spine fracture in mother +
• Social Hx: Non-smoker, non-drinker, single, retired High School teacher
• System Review

8. Back Pain: Summary
• (For students to practice)

9. Clerking:
1) Details of Back Pain
Triggers: Injury, fall, lifting a heavy weight
2) Associated symptoms
- symptoms due to S/C compression
- symptoms of malignancy, TB
3) PMH: Hx of cancer, TB, arthritis
4) Obs:&Gynae: Menopause, Hysterectomy
5) PSH:
6) Drug Hx: Corticosteroids, HRT, traditional medicine
7) FH: cancer, osteoporosis
8) SH: Smoking, alcohol
9) System Review
Details of back pain: SOCRATES + morning stiffness
TB, Malignancy (lungs, breast, bowel, lymphoma):
 Constitutional symptoms
 TB/Lung cancer: SOB, chest pain, cough, haemoptysis
 Bowel cancer: change in bowel habit, bleeding PR
Ureteric stones:
 Haematuria, UTI symptoms
Spinal cord compression:
Motor: Leg weakness
Sensory: loss of sensation
Bowel/Bladder: constipation, retention of urine
9

10. Back Pain: Physical Examination
• General observation:
 BMI (Thin or obese?)
• Vital signs: Temperature
• Peripherals:
 Hands: Clubbing, Heberden’s nodes/Bouchard’s nodes (OA)
 Eyes: anaemia, jaundice
 Neck: lymphadenopathy
• Spine (Back)
 Swelling, tenderness, ROM
 SLR test
• CNS: Any focal neurological deficit?
• Malignancy: Breast? Lungs? Abdomen?

11. Back Pain: Diagnosis
• Provisional Dx: Osteoporosis with VCF
• D/Dx:
 Spine metastasis
 TB Spine

12. Back Pain: Physical Examination Findings
• BMI 17
• Tenderness over lower thoracic spine
• Restricted spine movement
• SLR test negative
• No focal neurological deficit
• Other systemic examination: NAD

13. Back Pain: Investigations
• FBC
• ESR
• LFT
• RP
• Ca+2, PO4, ALP
• Serum immunoglobulins
• X-ray Thoracolumber Spine
• Chest X-ray
• DEXA Scan

14. Back Pain: Investigation Results

15. Back Pain: Final Diagnosis
• Osteoporosis with CVF T12

16. Back Pain: Management of Osteoporosis with CVF
• Non-pharmacological
• Fall precaution
• Exercise (weight-bearing exercise, balance exercise)
• Pharmacological
• Pain relief
• Bisphosphonates (Alternative: Denosumab)
• Calcium and Vitamin-D Supplement