1. Lower Back Pain

2. Definitions Most backache is ‘mechanical low back pain’ o Symptoms cannot be ascribed to a pathology (infection, tumour, osteoporosis, fracture, radicular syndrome) Radicular – nerve root pain Acute - 12 weeks Recurrent – New episode after pain free for 6 months Affects 80-90% men and women between 30 and 50.

3. Presentation HistoryRed Flags Consider occupation, hobbies or sport PMH: o Steroid predisposes to osteoperosis o History of malignancy/myeolma Patients management Recent Violent Trauma Minor trauma with osteoperosis 50 Hx – Cancer, drug abuse, HIV, Immunosuppression, corticosteroids Constitutional symptoms Recent bacterial infection Pain: o Worse supine, night, thoracic, constant, non-mechanical, unchanged despite treatment o Morning stiffness o Saddle anaesthesia or bladder/bowel change

4. Examination BasicsRed Flag Undressed, revealing spine, standing Inspection, palpation, function and brief neurology o More detailed if red flags Passive SLR o For nerve root pain o Sensitive (90%) o Not specific (20%) Structural Deformity Severe/progressive deficit Laxity of anal sphincter Perianal/perineal sensory loss Major Motor Weakness Cauda Equina o Bladder dysfunction o Sphincter disturbance o Saddle anaesthesia o Lower limb weakness o Gait disturbance

5. Differential Diagnosis Peripheral Arterial Disease o Pain on walking, relieved by rest o Absent or weak pulses o Include smoking and other vascular disease Infection o Never forget TB (osteomyelitis) o HIV predisposes infections o Pyelonephritis Dissecting aortic aneurysm o Pain in back radiating through to front Facet Joint o Acute or chronic o Worse morning/standing o Pain over facets – worse on extension Spinal Stenosis o Gradual onset o Unilateral/bilateral leg pain, numbness worse on walking o Resolves on sitting/leaning forwards, crouching down o Diagnose with MRI Ankylosing Spondylitis o Young man with lower back pain and stiffness o Improves with activity o Peripheral arthritis

6. Investigations If simple low back pain no investigation required Plain XR o 120 CXRs, rarely affects management. Should not be used routinely o Fracture suspected o Metastatic carcinoma (prostate = sclerotic), (lung, thyroid, kidney = osteolytic), (breast = both) o Collapse in osteoperosis o Paget’s disease CT Scan o Best for spondylolisthesis and stress fractures MRI o Good picture of soft tissues, will show nerve compression o Displays disc lesions best Bloods o FBC, ESR, CRP – cancer, infection, inflammation o LFTS -  ALP in metastatic disease and pagets o PSA – Prostate carcinoma o Urine hydroxyproline – Increased in Pagets

7. Management Low Back Pain o Information, reassurance and advice – NOT BED REST, Stay Active! o Regular pain relief o Referral Consider physical treatments, manipulation if not resuming normal activities after a week or two. MDT approaches – CBT and ‘back schools’ Red Flag o Urgent refrral e.g. Cauda Equina to neuro/spinal surgeon Chronic Pain, psychosocial factors and yellow flags o Belief that activity is harmful o Sickness behaviour o Social withdrawal o Emotional problems o Problems at work o Claims, compensation etc. o Overprotective family o Inappropriate expectations of Rx (including low) Try and challenge behaviours

8. Referral Guidance Immediate o CES Urgently o Serious spinal pathology o Progressive neurological deficit- refer after 1 week o Nerve root pain not resolving after 6 weeks, to be seen within 3 Soon o Inflammatory conditions suspected e.g. AS o Simple back pain and not resuming activities after 2-3 weeks

9. Questions 1.A 34-year-old man reports the sudden onset of back pain after bending over to tie his shoe laces. There is tenderness over the lumbar spine on examination and leaning back worsens the pain. Neurological examination and straight leg raising is normal 2. A 76-year-old man reports pain is his buttocks when he walks the dog. The pain comes on after around 500 yards and resolves when he stops. He has a past history of chronic obstructive pulmonary disease and ischaemic heart disease. Neurological examination is normal and the foot pulses are difficult to feel in both feet 3.A 68-year-old man obese man presents with a one day history progressively severe lower back pain. There was no obvious trigger. Abdominal examination is unremarkable. Blood pressure is 90/60 mmHg and his pulse is 120 bpm Select from the following A. Peripheral arterial disease B. Prolapsed disc C. Facet joint pain D. Perforated duodenal ulcer E. Ruptured abdominal aortic aneurysm F. Pyelonephritis G. Ankylosing spondylitis H. Rheumatoid arthritis I. Crush fracture J. Spinal stenosis

10. Questions A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis? A.Inflammatory arachnoiditis B.Peripheral arterial disease C.Raised intracranial pressure D.Spinal stenosis E.Lumbar vertebral crush fracture