Musculoskeletal Back Pain: Causes and Management Strategies

1. Back Pain • Alastair Jones

2. Back Pain • Back pain is a very common problem that will affect most people at some point during their lives. • 90% is musculoskeletal / non serious and will get better within 8-12 weeks. It can be treated with analgesia and keeping mobile. • Need to identify the 10% with serious pathology

3. Musculoskeletal Back Pain • Commonly lower back pain. It may occur gradually due to years of poor posture.It may develop suddenly after lifting or awkward movement. Sometimes it can develop for no identifiable reason... • Upper or middle back pain is less common due to the more limited mobility of the spine at that level. However a trapped or injured nerve can cause pain still. • Whilst it may not be serious it can be very debilitating for the patient and expensive to both the NHS and the economy as a whole.

4. Musculoskeletal Back Pain • Risk factors: • Being overweight • Smoking • Pregnancy • Steroids (osteoporosis) • Stress • Depression

5. Musculoskeletal Back Pain • Presentation - lower back pain, no specific cause. Pain is dull, diffuse, poorly localised. No neurology on examination, -ve SLR and rare to get pain beyond knee. May be secondary to OA, degenerative, sprains and strains, fibromyalgia. Often recurrent. • Serious pathology more likely if skeletal pain, neurology or extra-spinal pathology

6. Serious Causes • Skeletal: • Fractures • Infection - abscess, discitis, osteomyelitis • Malignancy • Nerve syndromes: • Disc herniation - CES, root impingement • Canal stenosis • Arthritis

7. Serious Causes • Extra-spinal: • AAA • Renal calculi / UTI • appendicitis / psoas abscess / rectal cancer • Endometriosis / PID / ovarian cysts • Lymphoma / lymph node enlargement / cancer

8. Essential Questions • Where is the worst pain? Where is your pain? • When did you last pass urine / open bowels? • Does your bottom / genital area feel normal? • Can you feel a full bladder? Any urine incontinence? • Can you tighten your anus?

9. Essential Examination • Neurology - tone, power, sensation, reflexes, SLR • ROM spine • PR - anal tone and sensation • Post void residual volume

10. Red Flags

11. Back Pain - Red Flags • Hx of cancer or recent infection • Immunosuppressed - HIV, IVDU, steroids, chemotherapy, transplant patients... • Age < 20 or > 55 • Bilateral sciatica symptoms • Bowel or bladder dysfunction • Saddle or genital paraesthesia

12. Back Pain - Red Flags • Trauma • Foot drop or other discrete neurology • Systemic illness - fever, malaise, wt loss • Loss of anal tone • Retention - PVR > 100 mls • Significant leg weakness

13. Investigations • If no red flags... • Otherwise may require: • bloods • radiology - USS/CT/MRI

14. Management • Non serious back pain can usually be managed conservatively: • Analgesia • Mobilisation / physiotherapy / gentle exercise • Education / information leaflets • GP management

15. Disc Disease • 50%resolve / back to work after 2 months • 90% resolved after 6 months • Consider surgery after 2 months if sciatica symptoms not improving. Surgery ineffective for LBP • Conservative vs surgery - 90% good outcome at 6 months

16. Protruding Discs

17. Corda Equina Syndrome • Severe LBP • Bilateral sciatica • Lose L5/S1 • Bladder or bowel dysfunction • Saddle paraesthesia

18. Corda Equina Syndrome • Have a high index of suspicion if any red flags • Needs emergency MRI / speciality referral • Outcome for bowel / bladder / sexual function better if decompressed within 48 hours. However, sooner the better!

19. Other Serious Causes • Maintain a high index of suspicion. Non-serious back pain is a diagnosis of exclusion. • Do investigate for ?AAA, fracture etc as indicated by history and examination. These should managed as is appropriate.

20. Wedge Fracture • Easy to miss so look carefully!

21. AAA • Need to rule out as people get older...

22. Psoas Abcsess

23. Chronic Back PainYellow Flags • ABCDEFW approach which highlights patients at risk of developing chronic back pain • Attitude - Coping, getting on with it vs Not coping • Beliefs - do they believe there must be something serious going on. Catastrophisation... • Compensation - awaiting payment (RTC, work injury)

24. Chronic Back PainYellow Flags • Diagnosis - how was it communicated I.e. Iatrogenic. E.g. "Your spine is crumbling" • Emotions - anxiety / depression / emotional difficulties more likely to lead to chronicity • Family - over bearing or under supportive... • Work - Poor relationship with work more likely to lead to chronicity also

25. Other Resources • NICE CG88 for chronic back pain • The Back Book - useful patient resource available from the stationary office.

26. Questions

27. Summary • 90% of cases are non-serious and better after 2 months • Analgesia and mobilisation/ physiotherapy • Remember to exclude serious pathology - infection, malignancy, discs, fracture, AAA, CES...

28. Summary - Red Flags

29. Summary - Red Flags • Hx of cancer or recent infection • Immunosuppressed - HIV, IVDU, steroids, chemotherapy, transplant patients... • Age < 20 or > 55 • Bilateral sciatica symptoms • Bowel or bladder dysfunction • Saddle or genital paraesthesia

30. Summary - Red Flags • Trauma • Foot drop or other discrete neurology • Systemic illness - fever, malaise, wt loss • Loss of anal tone • Retention - PVR > 100 mls • Significant leg weakness