Approach to Back Pain

Dr Sivaneasan Kandiah

General Approach
Distinguish between acute and chronic back pain
History and physical examination
Rule out bad things Red Flags
Neurological deficit
History advanced cancer
Infection

 Chronic back pain

Lasting for > 3 months
Not an acute back pain that persists
low back pain of unspecified pathology

Complex with physiological, psychological and

psychosocial influences
Yellow Flags

Differential Diagnosis
Mechanical

Lumbar strain or sprain >70%

Degenerative disc or facet arthropathy
Herniated disc
Osteoporotic compression fracture
Spinal stenosis
Spondylolisthesis

 Nonmechanical causes

Infection
Inflammatory RA, SLE, Ankylosing spondylitis
Malignancy
Degenerative disease

 Non vertebral causes

GIT Posterior stomach ulcer

Pancreas Tumor, pancreatitis
Renal Calculi
Aortic aneurysm
Gynaecology Ovarian/pelvic tumors, dysmenorrhea

History Taking
Pain history onset, location, severity, quality, duration,
radiation, aggravating or relieving factors
Neurological symptoms
Constitutional symptoms
Past history
Treatment
Work and lifestyle
Social and psychological issues

Red Flags
Less than 20 or older than 50, with backpain for the first time.
Trauma.
The pain is constant and getting worse.
Pain is worse at night or when supine.
Previous cancer history.
Steroid use, IV drug use, UTI, immuno-suppressed.
Fever and/or weight loss.
Neurological signs such as weakness, numbness, saddle
anesthesia or bowel/bladder incontinence

Yellow Flags
Belief that back pain is harmful and potentially disabling
Reduced activity levels
Low mood
Expectation of passive treatment rather than active
participation
Previous history of back pain and claims (time off)
Problems at work, poor job satisfaction
Overprotective family or lack of support

Physical examination
Inspection deformity, ROM
Palpation deformity, trigger points, muscle guarding
Neurological
L3-4
sensory; medial foot
Motor; knee extension
Patellar reflex

L4-5
Sensory; dorsal foot
Motor; dorsiflexion of ankle and big toe

L5-S1
Sensory; lateral foot
Motor; plantarflexion
Achilles reflex

Straight leg raise

Investigation
FBC, ESR for infection
Imaging indication

Neurological deficit
Significant h/o trauma
Signs of infection
H/o cancer
h/o osteoporosis
Acute pain lasts > 2 weeks with no red flags

Management General principle

Acute pain

Rule out red flags referral if present

Reassurance
Symptomatic pain relief with NSAIDS and COX-2 inhibitors
Advice to continue ordinary activities, avoid bed rest
Avoidance of over investigation

Chronic pain
Multidisciplinary approach
Pain management
Activity modification, OT, PT