54 Back pain

Questions

What is the most common cause of back pain?

What are suspicious features of back pain?

What are the causes of cervical and lumbar pain?

Lower back pain is extremely common: 10% of the population suffer at any one time and 90% at some time in their life. However, 90% of causes are non-specific (mechanical back pain) and less than 10% have an underlying pathology. Other non-spinal causes should be remembered (e.g. aneurysm or visceral disorder).

Suspicious features of back pain

Tumours and acute spinal compression must not be missed; suspicious features are:

bladder and bowel symptoms, saddle anaesthesia (buttocks), new bilateral sciatica (red flag symptoms of spinal cord compression)

age < 20 or > 50 years; acute onset in the elderly

weight loss (malignancy)

fever (infection)

active cancer or history of cancer

recent bacterial infection

night/rest pain

back pain that persists for more than 3 months.

Managing back pain

Most back pain (90%) resolves in 6 weeks with or without any treatment.

Conservative management

Lifestyle adaptation, analgesia (NSAIDs, weak opiates), anaesthetic/steroid injections, heat treatments, back supports, physiotherapy.

Activity restriction

In general, the patient should limit strenuous activity but remain active, with early mobilization.

Surgery

This is almost never appropriate and so is only used for 0.5% of affected patients However, urgent surgical decompression is required for acute spinal compression.

Lower back pain: the lumbar spine

Causes of low back pain are given in Table 3.54.1.

Table 3.54.1 Causes of lower back pain

Structural	Mechanical, facet joint osteoarthritis (spinal stenosis), prolapsed intervertebral disc, spondylolithesis/spondylolysis
Neoplastic	Primary or secondary
Infection	Osteomyelitis, discitis
Metabolic (Ch. 65)	Osteoporosis (fractures), Paget’s disease, osteomalacia, ankylosing spondylitis, hyperparathyroidism (Ch. 41)

Mechanical pain

The patient is usually 20–55 years, with pain felt in the lower back, buttocks and thighs; there are no weight loss or systemic symptoms. There may be a history of physical activity, and neurological examination is normal. Suspicious features should be investigated further. Management is as above.

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