Back pain

Question 1

Classic presentation of non-specific back pain

Answer 1

• Lumbosacral area
• Varies with posture and time
• Worsened by movement
• Typical onset after twisting/lifting with something heavy or vibration tool use

Question 2

Red flags for back pain

Answer 2

• Thoracic location
• Severe localised pain relieved by lying down
• Wakes from sleep
• Saddle anaesthesia
• Lower limb neurological signs - weakness/parasthesia
• Bowel/bladder disturbance
• Constitutional symptoms - weight loss/night sweats
• Age onset <20 or >55
• Steroids/IV drug use
• Stiffness in morning >30 mins
• Pain improves with exercise

Question 3

Examination for non-specific back pain

Answer 3

• No red flags
• Exacerbated by movement

Question 4

Investigations for non-specific back pain

Answer 4

None unless you suspect it isn’t just non-specific back pain

Question 5

When would you investigate back pain?

Answer 5

• Red flags - MRI if soft tissues/osteomyelitis
• If suspect osteoporotic # - spinal x-ray
• Urine dip if suspecting pyelonephritis
• ESR/CRP if suspect rheumatological cause
• WCC/CRP if suspect discitis/osteomyelitis

Question 6

Management of non-specific back pain

Answer 6

• STarT back tool - assess risk of back pain disability
• Advice - sources of info eg backcare.co.uk, chartered society of physiotherapy patient info
• Encourage activity
• OTC NSAID 1st line (+PPI)
• If contraindicated or not working - weak opioid eg codeine
• If muscle spasms causing - short course (days) of Diazepam
• Physio, group exercises and CBT if more chronic

Question 7

When is radiofrequency denervation considered?

Answer 7

• Failed to respond to non-surgical treatment
• Main source pain related to branches of medial branch nerve
• Pain rated as 5 or more on visual analogue scale or equivalent

Denervate the nerves which carry pain signals from the joints and have no other function really

Question 8

Management dependent on STarT score

Answer 8

• Low risk patients: can be managed with reassurance and encouragement to remain active, early managed return to work and simple analgesia
• Medium risk patients: should be managed as per low risk in addition to offering a referral to physiotherapy
• High risk patients: should be referred to psychologically informed physiotherapy.

Question 9

How long for non-specific back pain to resolve?

Answer 9

• 4-6 weeks usually