Back Pain
Definitions:
The term ‘acute’ is used to describe pain that has been present for less than
three months (Merskey 1979); it does not refer to the severity or quality of
pain. Chronic pain is pain that has been present for at least three months
(Merskey and Bogduk 1994).
The following is a definition of thoracic spinal pain developed by the
International Association for the Study of Pain (Merskey and Bogduk 1994):
Pain perceived anywhere in the region bounded superiorly by a
transverse line through the tip of the spinous process of T1, inferiorly
by a transverse line through the tip of the spinous process of T12, and
laterally by vertical lines tangential to the most lateral margins of
the erector spinae muscles. This area can be divided into upper,
middle and lower thirds. Pain felt lateral to this area is defined as
posterior chest wall pain, and does not constitute thoracic spinal
pain.
Epidemiology
Lifetime incidence of back pain exceeds 70% in most industrialized nations.
Back pain occurs at all ages and is the most common reason for work
disability in patients younger than 40 years.
Incidence
About one half of the population will report back pain over 12 months.
Prevalence
15,000 to 20,000 per 100,000 persons is the average 1-year prevalence.
Red and yellow flags of back pain
Table ‘Red flag’ pointers to serious low back pain conditions
Age > 50 years
History of cancer
Temperature > 37.8°C
Constant pain - day and night
Weight loss
Symptoms in other systems, e.g. cough, breast mass
Significant trauma
Features of spondyloarthropathy, e.g. peripheral arthritis
Neurological deficit
Drug or alcohol abuse
Use of anticoagulants
Use of corticosteroids
No improvement over 1 month
Possible cauda equina syndrome
• saddle anaesthesia
• recent onset bladder dysfunction
• severe or progressive neurological deficit
Table Non-musculoskeletal causes of thoracic back pain
Heart
• myocardial infarction
• angina
• pericarditis
Great vessels
• dissecting aneurysm
• pulmonary embolism (rare)
• pulmonary infarction
• pneumothorax
• pneumonia/pleurisy
Oesophagus
• oesophageal rupture
• oesophageal spasm
• oesophagitis
• oesophageal cancer
Subdiaphragmatic disorders of • gall bladder
• stomach (including ulcers)
• duodenum (including ulcers)
• pancreas
• subphrenic collection
Miscellaneous infections
• herpes zoster
• Bornholm disorder
• infective endocarditis
Psychogenic
Table Thoracic back pain: red flag pointers
Fracture Pointer
• Major trauma
• Minor trauma
- osteoporosis
- female>50year
- male>60year
Malignaney Pointer
• Age >50
• Past history malignancy
• Unexplaned weigh loss
• Pain at rest
• Constant pain
• Night pain
• urns at multiple sites
Infection pointer
• Fever
• Night soviets
• Risk factors for infixion
Other serious conditions
• Chest pain/heaviness
• Shortness of breath, cough
Yellow flags are pyschosocial factors shown to be indicative of long-term
chronicity and disability:
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A negative attitude that back pain is harmful or potentially severely
disabling
Fear avoidance behaviour and reduced activity levels
An expectation that passive, rather than active, treatment will be
beneficial
A tendency to depression, low morale, and social withdrawal
Social or financial problems
Lower back pain
Anatomical and clinical features of thoracic back pain
Although there is scant literature and evidence about the origins of pain in
the thoracic spine, the strongest evidence indicates that pain from the
thoracic spine originates mainly from the apophyseal joints and rib
articulations.
Management
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Advise to resume normal activities as soon as possible and to “let
pain be their guide” as to the appropriate level of activity. Explain
that this will help to relieve symptoms and reduce the risk of chronic
disability.
Encourage a prompt return to work—although manual handling may
be an issue, and training in lifting may be advisable. Discuss whether
you might need to liaise with their workplace.
Investigations
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Imaging tests are not recommended in acute non-specific low back
pain in the absence of clinical ‘red flags’. (Level III-2 evidence).
The majority of imaging tests for acute low back pain presentations
find no abnormalities, or only minor changes. Imaging findings are not
strongly associated with acute low back pain symptoms.
Unnecessary x-rays and CTs subject the patient to risks of radiation
exposure.
The Australian guideline Evidence-Based Management of Acute
Musculoskeletal Pain recommends against routine use of plain x-rays or
other imaging tests such as magnetic resonance imaging (MRI) or
computerised tomography (CT) in the absence of red flags in non-specific
low back pain of less than 12 weeks duration. This guideline states that xrays are unhelpful in identifying the cause of pain and do not contribute to
greater improvement in a patient’s physical function, pain or disability.
Numerous other international clinical practice guidelines also recommend
against imaging for acute non-specific low back pain.
NHMRC (2003) Guidelines: “Plain x-rays of the lumbar spine are not
routinely recommended in acute non-specific low back pain as they are of
limited diagnostic value and no benefits in physical function, pain or
disability are observed.”
The main investigation is an X-ray, which may exclude the basic
abnormalities and diseases, such as osteoporosis and malignancy.
If serious diseases such as malignancy or infection are suspected, and the
plain X-ray is normal, a radionuclide bone scan may detect these disorders.
CT scanning has a minimal role in the evaluation of thoracic spinal pain.
Other investigations to consider are:
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FBE (full blood examination) and ESR (erythrocyte sedimentation
rate. It is a test that indirectly measures how much inflammation is in
the body, very high levels occur with multiply myeloma)
serum alkaline phosphatase
serum electrophoresis for multiple myeloma
Bence-Jones protein analysis
Brucella agglutination test
blood culture for pyogenic infection and bacterial endocarditis
tuberculosis studies
HLA-B27 antigen for spondyloarthropathies
ECG or ECG stress tests (suspected angina)
gastroscopy or barium studies (peptic ulcer)
MRI
References:
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http://www.nhmrc.gov.au/publications/synopses/cp94syn.htm NHRMC Evidencebased management of acute musculoskeletal pain
Back Pain: Medical Topics: First Consult
John Murtagh’s General Practice, 4th ed. Low back pain and thoracic back pain
About ESR: http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm
http://www.bmj.com/content/326/7388/535.full Chronic back pain: 10 minute
consult
www.bmj.com/content/327/7414/541.full.pdf Acute back pain: 10 minute consult
NPS lecture on Managing acute low back pain in primary care