Transcript Back pain - Home - Department of Undergraduate Education

Community presentation:
Low back pain
Overview






Case history
Low back pain
Role of primary care
Indicators for chronicity, management guidelines,
referral criteria, imaging
Prognosis
Summary
Low back pain







Low back pain (pain, muscle tension or stiffness localised below
the costal margin and above the inferior gluteal folds, with or
without sciatica) is a common symptom
Often traumatic or work related
Most commonly treated in primary healthcare
A GP can expect 20 out of every 1000 patients on the list to
consult with back pain
Episodes are generally short-lived and self-limiting. Most pain
and related disability resolve within weeks (Pengel 2003)
However, important to rule out sinister cause of back pain
Chronic back pain accounts for 120 million lost working days/
year in the UK
Causes of low back pain



Age determines the most likely cause
15-30: Trauma, prolapsed disc, fractures,
pregnancy, ankylosing spondylitis
30-50: Degenerative joint disease, prolapsed disc,
malignancy
>50: Degenerative, osteoporosis, Paget’s,
malignancy, myeloma
Back pain and primary care




Main function of GP is diagnostic
Diagnostic triage: Simple lumbosarcal pain, nerve root pain, sinister pathology
History
To detect ‘red flag’ and ‘yellow flag’ (psychosocial) signs
Red flag
Yellow flag
Thoracic pain
Fever and unexplained weight
loss
Bladder/ bowel dysfunction
history of carcinoma
Progressive neurological deficit,
disturbed gait, saddle
anaesthesia
Age of onset <20 or >55
A negative attitude that back
pain is harmful
Fear avoidance behaviour
Expectation that passive rather
than active treatment is
beneficial
A tendency to depression, social
withdrawal
Samanta et al. BMJ 2003; 326; 535
Examination






Inspect for signs of trauma, inflammation
Assess for localised tenderness and increased
temperature
Define exact site of pain
Examine spine movements
Neurological exam of lower limbs
Straight leg raise (To test for mechanical cause
of sciatic pain)
Prognostic indicators for chronicity





GPs aim to prevent acute back pain becoming chronic
Important to identify those at risk for long term
disability as recovery increasingly less likely the longer
the problem persists
Transition from acute to chronic simple backache is
multifactorial (individual and workplace associated
factors)
Pyschosocial factors are important in this process
(Croft 1998)
Distress, depressive mood, and somatisation are
associated with chronicity (Pincus 2002)
Management








To gradually increase activity over days/ weeks, be as active as
possible. Stay at work/ return to work as soon as possible
Bed rest not recommended as treatment of simple back pain
Some evidence that behaviour therapy, antidepressants, back
schools, back manipulation can be effective (Koes 2006)
Regular analgesia
Paracetamol + NSAIDs e.g. diclofenac
Paracetamol-opioid compound e.g. co-codamol
Consider muscle-relaxant for short term use e.g. diazepam
No evidence that alternative interventions such as lumbar
supports, massage, acupuncture are effective (Koes 2006)
Referral criteria from primary care (NICE)
1.
2.
3.
4.
5.
6.
Cauda equina syndrome features (bilateral
lower limb root pain, saddle anaesthesia,
abnormal bladder/ bowel function)
Spinal pathology
Progressive neurological deficits
Underlying inflammatory disorder suspected
Unresolved root pain after 6/52
Not resumed normal activities in 3 months –
referral to a multidisciplinary back pain team
Imaging




Low association between abnormality on X-ray and
MRI and non-specific low back pain – abnormalities in
those without back pain just as common as in those
with back pain
Many patients with back pain show no abnormalities
Therefore, most guidelines suggest only referring for
imaging if there are red-flag signs
MRI is most effective for detecting spinal pathology
(Jarvik 2002)
Prognosis





Clinical course favourable in most cases
Widely believed that 90% of patients cease to consult
GP about low back pain after 3 months
In one study, only 25% of patients had fully recovered
after 12 months (Croft 1998)
Recurrences are common, however the severity is
generally less and does not always lead to a new visit
Only about 5% of people with an acute episode will
develop chronic lower back pain (Koes 2006)
Summary




Conservative management
Investigations not useful in most cases
Always consider psychosocial factors
Note red flag signs, cauda equina syndrome is a
neurosurgical emergency!
References
1.
2.
3.
4.
5.
6.
7.
Croft et al. Outcome of low back pain in general practice: a
prospective study. BMJ. 1998; 316; 1356-59
Jarvik et al. Diagnostic evaluation of low back pain with
emphasis on imaging. Am Int Med. 2002; 137; 586-97
Koes et al. Diagnosis and treatment of low back pain. BMJ.
2006; 332; 1430-34
Kumar and Clark
Oxford handbook of clinical medicine
Pincus et al. A systematic review of psychological factors as
predictors of chronicity / disability in prospective cohorts of
low back pain. Spine 2002; 27; 109-20
Samanta et al. 10-minute consultation: chronic low back pain.
BMJ. 2003; 326; 535
Questions?