1. Back Pain Examination, assessment, red flags, Good Back Guide.
Jon Dixon, Bradford VTS

3. 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

4. Causes of back pain 1

5. 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.)

6. Structures that cause nerve root compression

7. L4/L5/S1 Radiculopathy

8. Straight Leg Raising

9. Piriformis syndrome
Pain from piriformis muscle – irritation of sciatic nerve passing deep or through it
Pain on resisted abduction / external rotation of leg

10. 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.

11. Cauda Equina syndrome (spinal canal compression)

12. Spinal Stenosis

13. 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

14. Schobers Test

15. Fabere test

16. Pelvic Compression Test

17. 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

18. Yellow flags 1

19. 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

20. 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

21. Referred pain Pleuritic pain Upper UTI / renal calculus
Abdominal aortic aneurysm
Uterine pathology (fibroids)
Irritable bowel (SI pain)
Hip pathology

22. 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

23. 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.

24. No evidence for: Short wave diathermy TENS Spinal manipulation
Traction
Acupuncture
Exercises
Spinal cortisone injections

25. Occupational issues

26. 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)

27. Blocks to returning to work (blue flags!)
perceived work load
low pay
management attitudes
poor support
loss of confidence
depression

28. JD’s top tips for back pain.
Patient who attends a second time with “simple” back pain- get them to strip to their underwear!

29. Top tips
True sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.

30. Top tips
With radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)

31. Top Tips
Physios are very good at managing the psychological aspects of chronic pain.

32. 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.