Diagnosis of Back Pain

Back Pain

• Back pain is second to the common cold as a cause of lost days at work.
• About 80% of people have at least one episode of low back pain during their lifetime.
• The most common age groups are the 30s - 50s.
• It usually feels like an ache, tension or stiffness in your back.

Broad Categories of Back Pain

1. Nonspecific low back pain
2. Radiculopathy or spinal stenosis
3. Back pain potentially associated with another specific spinal cause

Size in General Practice

Condition	Percentage
Compression Fracture	4%
Spondylolisthesis	3%
Tumours	0.7%
Ankylosing Spondylitis	0.3%
Infections	0.01%
Non-specific LBP	90%

Non-specific Low Back Pain

• Tension, soreness and/or stiffness in the
  • lower back region for which it is not possible
  • to identify a specific cause of the pain
• Several structures in the back, including the
  • joints, discs and connective tissues, may
  • contribute to symptoms

Mechanical Problems

• A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways.
• The most common mechanical cause of back pain is a condition called intervertebral disk degeneration.
• Muscle tension: happens when the muscle is over-stretched or torn, resulting in damage to the muscle fibers.

Site of Lower Back

• The lower back is commonly defined as the area between the bottom of the rib cage and the buttock creases.
• Some people with non-specific low back pain may also feel pain in their upper legs, but the low back pain usually predominates.

Spondylolisthesis (Displacement): Is a condition in which one vertebra slip forward over the one below it

Specific Causes of Low Back Pain

• type of Degeneration of discs joints

  • Inflammation

    • Ankylosing spondylitis, rheumatoid arthritis

  • Infection

    • Osteomyelitis, abscess, tuberculosis

  • Neoplastic

    • Myeloma, lymphoma, cancer

  • Metabolic

    • Osteoporosis, osteomalacia, Paget’s disease

  • Others

    • Sickle-cell disease, claudication

Causes of Low Back Pain

• Mechanical, most common cause (Sprains and strains)
• Metabolic
• Inflammatory
• Active infection
• Fracture
• Neoplastic
• Referred pain
• Pregnancy

Symptoms

• 80% to 90% of attacks of low back pain resolve in about 6 weeks.ZOSCE
• Back pain can range from a dull, constant ache to a sudden, sharp pain.
• Duration of pain:
  1. acute (less than 4 weeks).
  2. subacute (4 – 12 weeks).
  3. chronic (greater than 12 weeks).

Red Flags

1. Onset, age either <20 or >55 years.
2. Bowel or bladder dysfunction.
3. Spinal deformity.
4. Weight loss.
5. Lymphadenopathy.
6. Neurological symptoms.
7. History of HIV, corticosteroid therapy.
8. Unexplained fever.
9. Duration more than 6 weeks.

Yellow Flags

1. Belief: If the patient believes that the back pain is serious - usually cancer.
2. Compensation: Is the patient awaiting payment for an accident/injury at work/RTA?
3. Emotions: Patients with other emotional difficulties such as ongoing depression and/or anxiety.
4. Work-related factors.
5. Family: Problems with families, either overbearing or under supportive.

Psychological Factors

• Believe pain and activity are harmful
• Fear avoidance behavior
• Believe passive treatments will work
• Low mood

Occupational Factors

• Poor job control
• Low job satisfaction
• Recent hire
• Limited work skills

Socio-occupational Factors

• Financial issues
• Misunderstandings
• Unhelpful beliefs from family & friends
• Social isolation

Sciatica

• Is a bulging or herniated disk presses on the sciatic nerve that travels down the leg, it can cause sharp, shooting pain through the buttock and back of the leg.
• There may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body.

Examples of Disc Problems

• Normal Disc
• Degenerated Disc
• Bulging Disc
• Herniated Disc
• Thinning Disc
• Disc Degeneration with Osteophyte Formation

Cauda Equina Syndrome

• Rare but serious condition
• It can cause weakness in the legs, numbness in the “saddle” or groin area, and loss of bowel or bladder control.

Diagnosis of Back Pain

History

1. The course of pain.
2. Is there evidence of a systemic disease?
3. Is there evidence of neurologic problems?
4. Occupational history.
5. Risk factors.
6. Red flags.
7. Yellow flags.

Additional History

• Circumstances associated with pain onset.
• Factors altering pain (stiffness at rest or at night, decrease with movement)
• Is pain present continuously or on & off?
• Effect of pain on activities.
• Effect of pain on sleep.

Mechanical Back Pain

• Deep dull pain
• Moderate in nature.
• Relieved by rest, and increased by activity.
• Diffuse and unilateral.
• Intensity increases at the end of the day and after activity.

Inflammatory Back Pain

• Gradually in onset.
• Throbbing in nature.
• Morning stiffness.
• Exacerbates by rest and relieved by activity.
• Intensity increases at night and early morning.
• It is chronic backache.

Nerve Root Compression

• Intense sharp or stabbing pain.
• Numbness and paraesthesia in the same distribution
• Radiation to dermatome like: foot or toe.

When to Consider MRI

• Spinal malignancy
• Cauda equina syndrome
• Infection
• Ankylosing spondylitis
• Fracture
• Inflammatory disorder