Rheumatology Made Simple : backache

BACKACHE

Back pain is a common complaint that we come across in our daily practice.

Most of the causes are not sinister but rather due to simple muscle strain that respond well to postural correction and analgesics.

However ,it is important to rule out serious causes by giving particular importance to presence of red flags in the history and investigate thoroughly if these are present.

MAIN CAUSES

SIMPLE MECHANICAL BACK PAIN

Usually affects the lower back and may be localized to  buttocks and thighs.

It can vary with posture and activity and can change in response to changes in posture and treatment.

It is dull and poorly localized

 

NERVE ROOT / RADICULAR PAIN

It is sharp and well localized

Usually affects a dermatome.

It is often accompanied by numbness and tingling.

Sciatica is an example of nerve root pain.

SINISTER CAUSES / RED FLAGS IN HISTORY

The presence of the following red flags indicate a sinister underlying pathology and demands further investigation of cause of Backpain

History of malignancy

History of excessive steroids  use.

Presence of systemic symptoms such as fever and weight loss.

Structural deformity

Persistent night pain

Progressive neurological defect and sensory or motor defecits.

 

CAUDA EQUINA SYNDROME

This is characterized by Saddle anesthesia , bladder disturbance , faecal incontinence and bilateral numbness or weakness in lower limbs.

EXAMINATION

A general examination should be undertaken

Particular focus should be on examination of the back and neurological examination of the legs.

BACK EXAMINATION:

Look for any deformity of the back and tenderness , signs of injury or wounds.

Perfom SLR Test : Passive Straight Leg raising test for diagnosing nerve root pain due to disc pathology.

INVESTIGATIONS

MRI is the best investigation for diagnosing Nerve Root Compression , Discitis and Neoplasms.

Other investigations to exclude underlying cause of back pain include:

Infection : Full Blood Count , CRP , Blood cultures , other inflammatory markers and Diagnostic biopsy

Malignancy : Liver and bone profile , PSA , Urinary Bence Jones proteins . Bone scana dn Protein Electrophoresis.

MANAGEMENT

Patients with simple mechanical back pain requires postural advice and comfortable sitting p osition and Adequate analgesia and muscle relaxants .

Analgesic ladder should be followed while prescribing analgesics. These include going from non-opiods eg paracetamol to opioids  such as co-codamol or oramorph.

Simple Mechanical pain has a good prognosis , 90 % recover at 6 weeks.

For other patients who don’t have simple mechanical back pain, management depends on treating underlying cause.

Any patient with symptoms suggestive of Cauda Equina requires immediate Neurosurgical  referral and management.