• discomfort, muscle tension or stiffness

    • area around lumbar spine

  • may radiate to goin, buttock or legs

    • referred somatic pain

  • associated with lumbar radicular pain

    • sciatica

  • acute \<6 wk

  • subacute 6wk - 3mo

  • chronic >3mo

  • 70-90% recover fully within 3mo

    • subsequent relapse common

history:

  • onset / duration

    • specific event

    • no apparent illness

    • trauam may indicate vertebral # or SIJ

    • pain that develops slowly may indicate serious pathology

  • site and radiation

    • somatic/radicular

    • ask about which pain is ‘dominant’ - what would you like to get rid of

    • radicular

      • shooting/stabbing

      • parathesia

      • below knee > above

      • narrow band

      • travelling

      • deep + superficial

    • somatic

      • dull

      • prox > distal

      • widea rea

      • static

      • deep only

  • precipitating and relieving factors

    • non specific = better @ rest, worse with actiity

    • opposite inflammation - ankSpond

    • disc =- prolonged sitting or forward flexion aggravates symptoms

    • leg dominant pain resolves with flexion and sitting and worsens with extension = spinal stenosis (if pulses ok)

  • severity and functional impact

    • activities/sleep

  • neurological deficit

    • cahgne in gait

    • perineal sesnation

    • sexual function

    • micturition

    • defaecation

  • symptoms of systemic illness

    • weight loss

    • fatigue

    • night sweats

    • fever

categories

Serious pathology

Red flags

  • Trauma

  • XR

  • Systemic features

  • unrelenting pain/worse at night

  • \<20yo or new back pain >50yo

  • history of cancer

  • systemic symptoms

  • IVDU

  • immunosuppression or steroids

  • CBC, CRP, ALP, Ca, PSA, XR, refer

  • Cauda equina

  • widespread or progressive neurological deficit

  • sphincter disturbance

  • Gait disturbance

  • saddle anaesthesia

  • refer immediately

Causes:

  • osteoporotoic or truama related vertbral # 4%

  • cancer involving lumbar spine (0.66%)

  • Inflammatory disease - ank spont (0.3%)

  • spinal osteomyelitis associated ivdu, uti, skin infection (0.01%)

Radicular nerve involvement

Non specific back pain

  • diagnosis of exclusion

Cauda equina syndrome

  • below L1-L2

  • T12-L1 = ciconus medullaris syndrome

Presentation

  • most cases sudden onset and progress rapidly within hours/days

  • can evolve slowly

  • Low back pain

  • bilateral leg symptoms

    • including pain

    • lower motor neuron weakness

    • sensory

  • saddle anaesthesia

  • urinary dysfunction

  • bowel distrubance

    • reduced anal tone on PR

  • sexual dysfunction

Management

  • address FIFE

  • Yellow flags

    • belief that back pain is harmful and potentially severely disabling

    • avoiding behaviours for fear of damaging back

    • past history of chronic pain, somatisation and pre-occupation wtih health

    • negative attitudes and outlook and a tendencey towards lowered mood and withdrawal from social activity

    • expectation that passive treatment > active treatment

  • Reassure

    • “days - weeks’ to get better

    • like an ankle sprain

    • won’t show on XR

    • gradually get back to usual activities

    • 90% with radicular pain start to improve within 6wks and be free of leg pain within 12 wks

    • not unusual to get flares

    • movement causing pain doens’t mean damage

  • advice re activity

    • stay active

    • simple stretching

    • walking as noramlly as possible

      • gradually increase activity like swimming

      • 30min/day

    • refer early to physiotherapy

    • reinforce recommendations with green prescription

  • Adequate analgesia

    • Paracetamol

      • although no better than placebo???

    • NSAID

      • small short term effect on acute low back pain without radicular pain

    • Codeine 30-60mg q4h

    • Tramadol 50mg q6h

    • conflicting evdience re muscle relaxants

    • TCA has place in chronic pain

  • alternative therapies

    • local heat therapy more effective compared to paracetamol/nsaid in first 48hrs