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 SacroiliitisSpondyloarthropathies 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.