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

14. ManagementManagement 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. AAAAAA Need to rule out as people get older...

22. Psoas Abcsess

23. Chronic Back Pain Yellow 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 Pain Yellow 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. QuestionsQuestions

27. SummarySummary 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. Hx of cancer or recent infection Immunosuppressed - HIV, IVDU, steroids, chemotherapy, transplant patients... Age 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