Back Pain
Examination, assessment, red
flags,
Good Back Guide.
Jon Dixon, Bradford VTS
Causes of back pain 1
Mechanical - Muscles and ligaments
Local tenderness, muscle spasm, loss of lumbar
lordosis, percussion tenderness over spinous
process
NO MOTOR/SENSORY/REFLEXIC LOSS
Causes of back pain 1
Causes of low back pain 2
Radicular low back pain
Herniated intervertebral disc commonest cause
but can be foraminal stenosis sec. OA / tumours
/ infection (rare)
TOP TIP not all pain referred down leg is
sciatica (facet joint disease / hip / SIJ / piriformis
syndrome etc.)
Structures that cause nerve root
compression
L4/L5/S1 Radiculopathy
Straight Leg Raising
Piriformis syndrome
Pain from piriformis
muscle – irritation of
sciatic nerve passing
deep or through it
Pain on resisted abduction /
external rotation of leg
Causes of low back pain 3
Lumbar Spinal Stenosis
Subtle presentation.
Bilateral radicular signs should alert to
possibility.
Pain on walking- worse on flat –(eases if
hunched over – shopping trolley sign!)
Can be mistaken for Claudication.
Admit if progressive / or else CT scan.
Cauda Equina syndrome
(spinal canal compression)
Spinal Stenosis
Causes of low back pain 4
Inflammatory – Ankylosing Spondylitis
Difficult to diagnose if early stages but:
Morning stiffness for > 30 minutes
Pain that alternates from side to side of lumbar spine
Sternocostal pain
Reduced chest expansion
Schobers test
Schobers Test
Fabere test
Pelvic Compression Test
Red Flags
 Weight loss, fever, night sweats
 History of malignancy
 Acute onset in the elderly
 Neurological disturbance Bilateral or alternating
symptoms
 Sphincter disturbance
 Immunosuppression
 Infection (current/recent)
 Claudication or signs of peripheral ischaemia
 Nocturnal pain
Yellow flags 1
Yellow Flags 2
Factors prolonging back pain
 Internal factors-Opioid dependency
 “External controller” patient-type; learned
helplessness; factitious disorder
 Mental health- depression or anxiety
 Interpersonal factors "Sick role“
 Stressors in relationships
 Environmental / societal factors- Disability
payments / Litigation / Malingering
Causes of back pain
 Structural
 Mechanical
Facet joint arthritis
Proplapsed
intervertebral disc
Spondylolysis / Spinal
stenosis
 Inflammatory
 SacroiliitisSpondyloart
hropathies
 Infection
 Metabolic
 Osteoporotic
vertebral collapse
Paget's disease
Osteomalacia
 Neoplasm
Ca Prostate
Ca Breast
Referred pain
•Pleuritic pain
•Upper UTI / renal calculus
•Abdominal aortic aneurysm
•Uterine pathology (fibroids)
•Irritable bowel (SI pain)
•Hip pathology
Imaging modalities
 Xrays good first line Ix if red flags, osteoporotic
fracture
 Bone scan (also good initial Ix if Xray nad and
red flags) - mets, infection, pagets, PMR
 CT Scan bone tumours fractures and spinal
stenosis
 MRI spinal cord, nerve roots, discs,
haemorrhage
 Dexa Scan Bone density
TREATMENTS
Simple Back Pain
(over 95% of cases)
Aim: to relieve symptoms and mobilise early.
Avoid Bed rest
Paracetamol (+nsaid if insufficient)
Avoid opiates if at all possible
No evidence that co-analgesics better than
paracetamol alone.
Muscle relaxants (diazepam / methocarbamol) small
additional benefit.
No evidence for:
Short wave diathermy
TENS
Spinal manipulation
Traction
Acupuncture
Exercises
Spinal cortisone injections
Occupational issues
Occupational issues
More sick leave : Less chance of recovery
4-12 w - 40% chance of still being off at 1
year.
Don’t need to be pain free to return to
work
MDT Rehabilitation programs:
psychological therapies; CBT; graduated
return to work (light duties)
Blocks to returning to work (blue flags!)
perceived work load
low pay
management attitudes
poor support
loss of confidence
depression
JD’s top tips for back pain.
 Patient who attends a second time with
“simple” back pain- get them to strip to their
underwear!
Top tips
 True sciatica means that the leg pain is
worse than the back pain- start examination
with them sitting on the couch.
Top tips
 With radiculopathy re-examine regularly,
carefully note findings and refer early if
weakness (foot drop can be irreversible)
Top Tips
 Physios are very good at managing the
psychological aspects of chronic pain.
Top Tips
 Sending someone to casualty is pointless
but can have a very useful ‘placebo’ effect in
showing the patient how impressed you are
with his or her pain.