Back pain

Differential diagnosis

  • Cauda equina
    • Urinary incontinence/retention
    • Faecal incontinence
    • Saddle anaesthesia
  •  Malignancy
    • Previous cancer, weight loss, thoracic
  • Infection
    • Fever, immunosuppression, IV drug use
  • Myeloma
    • Lethargy, infection, bleeding
  • Vertebral fracture
    • Trauma, steroids, osteoporosis
  • AS, RA
    • Morning stiffness
  • Non specific

Data gathering

  • Red flags
    • as above
    • age <20, >50
    • progressive
    • lying down doesn’t help
  • Examine
    • look, feel, move – back movements, straight leg raise, gait
    • neurological – sensation, reflexes, peripheral pulses

Clinical management (non specific low back pain)

  • Investigations (usually none needed but if persistent/atypical):
    • Bloods
      • FBC, U+E, LFTs, Ca, ESR, Serum protein electrophoresis
    • Urine BJP
    • Xray
  • Treatment
    • Lifestyle – lifting technique
    • Back exercises – knee to chest, pelvic thrust, knees side to side
    • Analgesia
    • Others: diazepam, tramadol, acupuncture, CBT, pain clinic
  • Follow-up / Safety-net
    • Non-specific low back pain – >6week – refer for structured exercise programme, manual therapy

Reference

Vale of York CCG acute low back pain pathway