Acute back pain is common and usually non-specific. It is important to thoroughly examine patients to rule out red flags indicating serious underlying causes. Non-specific back pain typically improves within two weeks with medications and staying active. Yellow flags like depression and fear of movement can slow recovery, so it is important to address psychosocial factors as well.

1. Acute back pain

2. What you should know The common causes How to assess patients and when to refer them The red & yellow flags How to manage patients with acute back pain.

3. Why back pain is important Common presentation Back pain affects up to ⅓ of the adult population 2nd most common cause of long-term absence from work If you miss an episode of spinal pathology, itcan result in permanent damage to the motor nerves.

4. Question 1 You see a 45 year old woman who has been experiencing pain in her right lower back for the last two days. The pain began after she reached to get something from a cupboard. There is no radiation of the pain and she has no neurological symptoms. There is no vertebral tenderness and no deformity of the spine. There is tenderness of the muscles of her lower back on the right. The patient has normal back movements but her movement forward is limited by pain. The straight leg raise is normal and there are no neurological signs. What do you think is the most likely diagnosis? Nerve root pain Compression fracture of the spine Non-specific low back pain Prolapse of the intervertebral disc

5. Classifications Acute low back pain - pain <6 weeks Sub acute low back pain - pain 6-12 weeks Chronic low back pain - pain >12 weeks Serious spinal pathology Infection, malignancy, fracture, and inflammatory causes e.g. ankylosing spondylitis Nerve root pain The sciatic nerve becomes trapped or irritated in the lumbosacral spine or the muscles of the lower back or buttock It may take 2 months for symptoms to resolve Non-specific low back pain Often triggered by a minor sprain or strain of the back May be mechanical - worsened by certain movement or postures Pain usually improves within two weeks.

6. Question 2 You make a diagnosis of non-specific low back pain. You explain the problem to the patient and reassure her that her symptoms are likely to improve within two weeks. She tells you that she works in an office and is able to take regular breaks and walk around. The patient takes paracetamol regularly for arthritis in her knees. You start ibuprofen in addition to the paracetamol. What else should you do? a. Advise the patient to rest in bed for a week b. Request an x ray of the thoracolumbar spine c. Advise the patient to stay active

7. History & examintion Rule out serious pathology by asking about red flags Ask about nerve root pain Examine all patients (usually a brief examination is sufficient) Examine other joints close to the back such as the hip joint for pain Pain can be referred from the hip joint to the back.

8. Back examination Inspection of the back and spine Palpation of the vertebral column, paraspinal muscles, and gluteal muscles Testing for range of movement of the back Examination of the hips Straight leg raise and sciatic stretch test Tone, power, reflexes, and sensation of the lower limbs.

9. Question 3 You see a 35 year old woman with acute back pain that you diagnose as non-specific low back pain. You note that she has been signed off work by a doctor three times in the last six months for back pain. She also takes antidepressant tablets for depression. Her symptoms of depression are stable and she is not suicidal. What else should you do in this consultation? a : Assess the patient for yellow flags b : Refer the patient to a psychiatrist c : Increase the dose of antidepressants

10. Yellow Flags Psychosocial barriers that inhibit recovery from back pain An inappropriate perception of back pain, e.g. belief that back pain is harmful and disabling belief that passive activity such as bed rest is better than staying active Lack of support at home and social isolation Mental health problems such as depression, anxiety and stress Problems at work e.g. bullying, job dissatisfaction Claims for compensation and benefits.

11. Treatment in primary care Aims Relieve pain Improve function Prevent recurrence of pain Prevent chronic pain Options Paracetamol, ibuprofen, co-codamol, diazepam Analgesic rubs Self-help: books, schools, exercises Sign off work

12. Question 4 You see an 80 year old man who was diagnosed with prostate cancer six months ago. He has had pain in his upper back that has worsened over the last week. For the last two days he has found it difficult to walk. On examination, he is tender over the mid thoracic spine. There is reduced power and increased tone in both legs. His plantar reflexes are up going. What should you do? a : Start paracetamol and steroids and review in 1week b : Refer the patient to hospital immediately c : Arrange an urgent outpatient appointment with the neurosurgeons

13. Spinal cord compression The thoracic vertebrae are a common site for compression of the spinal cord. The general symptoms of spinal cord compression include: Weakness and abnormal sensation of the lower limbs Pain over the vertebrae Urinary retention Faecal incontinence. The spinal cord ends at the level of the L1 and L2 vertebrae. Compression above this level causes upper motor neurone signs.

14. Caudaequina syndrome Compression of the spinal cord below the level of L2 vertebra. Causes lower motor neurone signs: Reduced tone in the limbs Absent or reduced reflexes Plantar reflexes that are down going. You should suspect a diagnosis of caudaequina syndrome in patients with: Gait disturbance and limb weakness - this is due to lower motor nerve compression Urinary retention or incontinence Faecal incontinence Saddle anaesthesia - this is numbness of the groin, buttocks, and back of the thighs. This is an emergency – refer immediately to hospital!

15. Red Flags Age <20 or >55 years Recent history of trauma Constant progressive pain - this includes pain that is not associated with movement and not relieved by lying down Thoracic pain Past history of malignancy Recurrent or prolonged use of corticosteroids Immunosuppression/HIV Substance misuse Being systemically unwell Unexplained weight loss Neurological symptoms such as weakness of the limbs Structural deformity of the spine.

16. Question 5 On a home visit, you see an 85 year old woman. Yesterday she slipped on a wet floor and landed on her bottom. Since then she has had severe pain in the middle of her back. She is able to walk but tells you the pain is better when she lies down. The pain is not radiating and she has no neurological symptoms. She is tender over the T10 vertebra. There are no neurological signs. On reviewing her records, you note that she fractured her wrist after tripping over a kerb a year ago. What’s your diagnosis? a : Compression fracture of the spine b : Non-specific low back pain c : Spinal cord compression due to bone metastases

17. Compression # Patients with a compression fracture of the spine due to osteoporosis sometimes find that the pain is better when they lie down. In patients with osteoporosis, if there are no contraindications, you should start calcium supplements and a bisphosphonate, such as alendronate. This can improve bone density and reduce the risk of further fractures.

18. Question 6 You see a 30 year old man who developed acute pain in the left buttock two days ago. The pain started when he was stretching before football. The pain has now moved down his leg and he also has some tingling in L foot. There are no red flags. On examination, there is tenderness of the Lbuttock. The straight leg raise test is positive on the Lside. The tone, power, reflexes, and sensation are normal in the lower limbs. What is the most likely diagnosis? a: Non-specific back pain b: Mechanical back pain c: Nerve root pain d :Caudaequina syndrome

19. Question 7 You make a diagnosis of nerve root pain. You explain the diagnosis and start paracetamol and ibuprofen. You advise the patient to stay active and gradually return to normal activities. What else should you do? a : Refer the patient to a physiotherapist for exercises and manipulation b : Advise the patient that it may take two months for his symptoms to settle c : Refer the patient to the neurosurgeons for spinal surgery d : Refer the patient to back school to educate him about back care

20. Question 8 You see a 50 year old woman who has been experiencing pain in her right lower back for the last four days. The pain is not radiating and there are no red flags. On examination, there is no deformity or tenderness of the vertebrae. You notice that the muscles of the right lower back are in spasm. There are no neurological signs. She takes co-codamol and diclofenac for arthritis in her knees but they are not helping her back pain. What else would you start? a : Amitriptyline b : Gabapentin c : Morphine d : Diazepam

21. Question 9 A 25 year old man has been experiencing back stiffness for the last six months. The back stiffness is worse in the morning but improves through the day. For the last week his back has been more stiff than usual and it takes him about an hour to loosen up. The pain does not radiate and there are no neurological symptoms. On examination, he has tenderness over the lumbar spine. The range of movement of the spine is limited. Schober's test is positive. What is the most likely diagnosis? a: Ankylosingspondylitis b: Non-specific back pain c: Mechanical back pain d: Rheumatoid arthritis

22. Question 10 You make a diagnosis of ankylosing spondylitis. What should you do next? a : Refer the patient immediately to hospital for a CT scan of the spine b : Make an urgent outpatient referral to the orthopaedic team c : Make an urgent outpatient referral to the rheumatology team

23. Key points The most common cause of acute back pain is non-specific back pain Most episodes of non-specific back pain resolve within two weeks Staying active is crucial in back pain management A thorough examination can reveal important findings and is very reassuring for the patient Patients who present with red flags can develop permanent damage to motor nerves Yellow flags are psychological factors that can inhibit recovery from back pain