Chronic Back Pain
Epidemiology
Aetiology
Clinical Features
Red flags:
Pattern 2: Extension pain
Pattern 3: Acute radioculopathy (unilat, constant, pain, paraesthesia)
Pattern 4: Spinal stenosis (b/l, intermittent, uphill > downhill)
History
Spinal cord compression - Red flag
Infection (discitis/ osteomyelitis/ epidural abscess) - Red flag
Introduce, consent, exposure (to underwear)
Look (standing/ sitting)
Feel
Move
Special tests:
DDX (? back/ referred)
Investigations
Bedside: Urine (BJ protein)
Blood: FBC (++WCC), CRP, ESR, blood cultures
Imaging: AP/ lat XR (lumbar/ cervical spine), CT (bone disease), MRI (soft tissue disease), bone scan (cannot detect MM)
Management
Links
www.hnehealth.nsw.gov.au/pain/
Source
Dr David Edis 2014
Dr David Penn 2014
- 70% adults
- Most common cause of time off work
- 95% non-specific cause
- Serious causes rare (<4%)
- 80% last <6 weeks
- 90% sciatica self-limiting
Aetiology
- Mechanical (soft tissue, disc, joints)
- Rheumatic (AS is always dx <40y)
- RAS (Reiter’s/ Psoriasis/ IBD)
- Neoplastic
- Infective
- Vascular
- Endocrine (osteoporosis/ pagets)
- Referred (abdo/ pelvic/ hip)
- Psychological
Clinical Features
Red flags:
- Cauda equina: urinary incontinence/ saddle anaesthesia
- Malignancy: Fever/ wt loss/ anorexia (some tumours cause fever)/ Previous Ca. Pain keeps getting worse, doesn’t go away
- Narcotics/Rest cannot relieve pain
- Infection: Fever
- Age: >50
- Pain duration: >1mo
- Sciatica: constant pain that fluctuates on posture
Pattern 2: Extension pain
Pattern 3: Acute radioculopathy (unilat, constant, pain, paraesthesia)
Pattern 4: Spinal stenosis (b/l, intermittent, uphill > downhill)
History
- Onset (acute/ chronic)
- Other leg sx (bilat neuro sx = impending cauda equina syndrome)
- Neuro (weakness, paresthesia) = spinal cord compression/ disc prolapse
Spinal cord compression - Red flag
- Bladder/ bowel incontinence and loss of sensation
- Sciatica (pain needs to radiate to foot: L4/L5 - ant; L5/S1 - posterior)
Infection (discitis/ osteomyelitis/ epidural abscess) - Red flag
- Severe constant back pain
- ?IVDU
- immunosuppresion (steroids/ diabetics/ chemo)
- fever
- migrant? (TB)
- Hx of cancer (metastasis)
- CRAB signs
Introduce, consent, exposure (to underwear)
Look (standing/ sitting)
- Surrounding: Walking aids
- Patient: Posture, gait, skin (scars), neck, spine (?assymmtery; '?' sign = excessive kyphosis + reduced lordosis = ankylosing spondylitis)
Feel
- Feel/ gentle hammer vertebrae from top down
- Paravertbral mm
- Sacroiliac joints
- PR (if necessary - spinal cord compression (sphincter tone))
Move
- Neck (C-spine): Flexion (Chin to chest), Extension (look up at ceiling), lateral flexion (ear on shoulder), rotation (look over shoulder)
- T+L-spine: Flexion (touch your toes), extension (lean backward), lateral flexion (slide hand down side of leg), rotation (twist at waist without moving hips)
Special tests:
- Schober's test = mark @ +10cm and -5cm above L5 (PSIS) while standing upright --> bend @ waist full forward flexion --> Measure (+ve = >20cm = AS)
- Straight Leg Raise = supine, raise leg to 90% hip flexion --> dorsiflex (Bragard test) --> (+ve = ipain @ back of thigh, alleviated by knee flexion + pain on contralateral leg raise = sciatic n irritation (intervertebral disc protrusion @ L4/L5, L5/S1))
- Femoral stretch test (prone with knee 905 flexed --> hyperextend @ hip; +ve = pain on anterior thigh - L2/3)
DDX (? back/ referred)
- Fracture
- Malignancy/ metastasis
- Spinal cord compression
- Infection (discitis/ osteomyelitis/ epidural abscess)
- Multiple Myeloma
- Trauma
- Others: AAA/ Cholecystitis/ Renal pathology
Investigations
Bedside: Urine (BJ protein)
Blood: FBC (++WCC), CRP, ESR, blood cultures
Imaging: AP/ lat XR (lumbar/ cervical spine), CT (bone disease), MRI (soft tissue disease), bone scan (cannot detect MM)
Management
- Treat cause (red flag causes)
- Reassurance (if no red flags)
- Psychologist for further management
- Prescribe activity > medications (avoid medication dependence)
- Analgesia (here)
Links
www.hnehealth.nsw.gov.au/pain/
Source
Dr David Edis 2014
Dr David Penn 2014