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Backache and its Assessment

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Backache is extremely common affecting 80%-90% of adult men and women between the ages of 30 and 50 years of age. Backache is a particular challenge because it is so common, demanding of medical resources and a major cause of physical, psychological and social disability. It is important to be able to assess backache accurately, with clear aims and methods to achieve appropriate management but also to identify important pathology without wasting resources.

Definitions of backache
  • Most backache (85-90%) will be so called simple low back pain (or 'mechanical low back pain') in which the symptoms by definition cannot be ascribed to a particular pathology (infection, tumour, osteoporosis, fracture, radicular syndrome, cauda equina syndrome). Simple low back ache is also called uncomplicated or non-specific low back pain and will vary with posture, activity, time and treatment.
  • Radicular (or nerve root pain) may occur with low back pain. Sciatica is a lay term for pain extending into the leg (buttock, thigh, calf or heel).
  • The classification into acute (less than 6 weeks), sub-acute (6-12 weeks) and chronic (>12 weeks) has been used in research but is less useful clinically because of the variable and recurrent nature of symptoms.
  • Recurrent low back pain has been defined as a new episode of pain after a symptom free period of 6 months1
Causes of backache

Many different pathologies can cause backache or pain referred to the back. However less than 1% of people with low backache will have a serious pathology (spinal tumour, infection, ankylosing spondylitis etc). Less than 5% of people with low back pain will have true nerve root pain and in the UK very few of these are treated with surgery. The rate of surgery in the USA is five time higher than the UK.2

How common is backache?
  • Backache is second only to the common cold as a cause of lost days at work.
  • 80-90% of adults (men and women equally) will have backache at some point in their life time (most prevalent between age 30 and 50 years), and 5-13% of children between the age of 10 and 16 years of age.
  • Backache was the reason for 14 million NHS GP consultations in 1994 and resulted in 7 million physical therapy sessions and 800,000 in-patient bed-days.
The aims of backache assessment
  • To recognise serious pathology.
  • To relieve pain.
  • To improve function.
  • To recognise and assess level of disability.
  • To identify barriers to recovery.
  • To prevent recurrence or persistence of symptoms.1
Method of backache assessment

This should take the form of diagnostic triage with the aims set out as above.

History

  • Red flags for possible serious spinal pathology from the history are:1
    • Age at onset less than 20 or over 50 years
    • Recent violent trauma;
    • Constant progressive, non-mechanical pain without relief from bed rest or postural modification
    • Pain unchanged despite treatment for 2-4 weeks
    • Severe morning stiffness
    • Patients unable to walk or self-care
    • Thoracic pain
    • Any past medical history of malignant tumour
    • Prolonged use of corticosteroids
    • Drug abuse, HIV, immunosuppression
    • Systemically unwell
    • Unexplained weight loss
    • Fever
    • Widespread neurological symptoms (including cauda equina syndrome)
    • Structural deformity
  • Cauda equina syndrome should be suspected if:
    • Bladder dysfunction (usually retention, sometimes overflow)
    • Sphincter disturbance
    • Saddle anaesthesia
    • Lower limb weakness
    • Gait disturbance
    Urgent referral is mandatory.
  • Identify 'yellow flag' symptoms. An attempt should be made to identify factors which predispose to chronic pain and long term disability (so called 'yellow flags'). This may, for example include inappropriate attitudes to pain and rehabilitation, inappropriate pain behaviour, work or compensation related issues, mood disturbance and emotional problems.3
  • Establish the length of history, the type and the severity of pain. Is the pain acute, sub-acute or chronic? Is the pain new, recurrent or an exacerbation? Guidelines are different for acute and chronic pain.
  • Differentiate between referred pain and nerve root pain. 70% of people with low back pain have pain referred to the buttock. The pain is dull and poorly localised, unlike the sharp well localised (see dermatomes) pain of nerve root pain. L5-S1 pain is common and goes to foot and toes. Often nerve root pain is exacerbated in the sitting position and ameliorated by standing or walking.1
  • Discogenic pain typically increases with sitting, flexion, coughing or sneezing.

It should be borne in mind that:

  • There is little correlation between symptoms, pathology and radiological appearances when assessing acute low back pain
  • Risk factors for acute low back pain, although poorly understood, are commonly reported as:heavy physical work; psychosocial factors (stress, anxiety, depression, cognitive dysfunction; job dissatisfaction; work related stress).4,5

Examination

A brief examination for acute back pain is recommended with patient undressed, revealing spine and standing. More detailed examination with neurological examination will be necessary if the history suggests it (e.g. red flags).
The brief examination should incorporate: inspection, palpation and an assessment of function.
Passive straight leg raising is often used to assist diagnosis of nerve root pain but it is highly sensitive (90%) and not very specific (20%).6

Investigations
  • Diagnostic imaging only if serious or specific pathology likely (e.g. red flags).7
  • Diagnostic imaging not useful in simple low back pain and likely to waste time and resources.8
  • MRI is the most useful investigation in nerve root compression, discitis and suspected neoplastic disease.7
  • Full blood count, ESR, CRP, urine analysis if cancer, infection or inflammation suspected.7

Management options

Simple low back pain

  • Give information, reassurance and advice.
  • DO NOT prescribe bed rest.
  • Advise to stay as active as possible.
  • Prescribe regular pain relief (paracetamol, non-steroidal anti-inflammatories) and consider short course of muscle relaxants.
  • Referral:consider physical treatments, manipulation or multidisciplinary approaches if not resuming normal activities or if off work. It is now recommended that such referrals be considered earlier than previously recommended, that is 'after a week or two' (see referral recommendations below). Multidisciplinary approaches include for example cognitive behavioural programmes and back schools.9,10

Suspected serious pathology or 'red flags'

Referral for further investigation.

High risk of chronicity, psychosocial factors

Identifying the 'yellow flags' should assist management. However evidence for interventions that work to change behaviour or prevent chronic pain and/or disability is thin.11 There is evidence to show that behavioural treatments may work as well as exercise therapy10 and that 'back schools' for chronic and recurrent low back pain may be most effective at getting people back to work, but may not be cost-effective.12

Referral guidance

Clinical Knowledge Summaries give advice on when to refer for specialist advice.7Remember when assessing whether to refer that motor deficits and bowel or bladder disturbances are more reliable than sensory signs.

  • If red flags suggest a serious condition refer with appropriate urgency. This means immediately for cauda equina syndrome.
  • If there is progressive, persistent, or severe neurological deficit refer for neurosurgical or orthopaedic assessment preferably to be seen within 1 week.
  • If pain or disability remain problematic for more than a week or two consider early referral for physiotherapy or other physical therapy.
  • If, after 6 weeks, sciatica is still disabling and distressing refer for neurosurgical or orthopaedic assessment preferably to be seen within 3 weeks.
  • If pain or disability continue to be a problem despite appropriate pharmacotherapy and physical therapy consider referral to a multidisciplinary back pain service or a chronic pain clinic.

These can also still be usefully thought of as 'immediate', 'urgent' and 'soon' referrals:

  • Immediately: cauda equina syndrome
  • Urgently: serious spinal pathology suspected;progressive neurological deficit; nerve root pain not resolving after 6 weeks.
  • Soon: inflammatory conditions suspected (e.g. ankylosing spondylitis); simple back pain not resuming normal activities after 2-3 months.
Prognosis

For acute low back pain:

  • Pain reduces rapidly for most within 1 month
  • 75% of people return to work within 1 month
  • 75% of people risk recurrence within 12 months.13


Document references
  1. European guidelines for the management of acute nonspecific low back pain in primary care, COST B13 Working Group (2004)
  2. Wheeler A; Pathophysiology of Chronic Back Pain. eMedicine, April 2006.
  3. Lee PW, Chow SP, Lieh-Mak F, et al; Psychosocial factors influencing outcome in patients with low-back pain. Spine. 1989 Aug;14(8):838-43. [abstract]
  4. Hoogendoorn WE, van Poppel MN, Bongers PM, et al; Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine. 2000 Aug 15;25(16):2114-25. [abstract]
  5. Linton SJ; Occupational psychological factors increase the risk for back pain: a systematic review. J Occup Rehabil. 2001 Mar;11(1):53-66. [abstract]
  6. Deville WL, van der Windt DA, Dzaferagic A, et al; The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine. 2000 May 1;25(9):1140-7. [abstract]
  7. Back pain (low) and sciatica, Clinical Knowledge Summaries (September 2008)
  8. Kendrick D, Fielding K, Bentley E, et al; Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001 Feb 17;322(7283):400-5. [abstract]
  9. Linton SJ, Nordin E; A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial. Spine. 2006 Apr 15;31(8):853-8. [abstract]
  10. Ostelo RW, van Tulder MW, Vlaeyen JW, et al; Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD002014. [abstract]
  11. van den Heuvel SG, Ariens GA, Boshuizen HC, et al; Prognostic factors related to recurrent low-back pain and sickness absence.; Scand J Work Environ Health. 2004 Dec;30(6):459-67. [abstract]
  12. Heymans MW, van Tulder MW, Esmail R, et al; Back schools for non-specific low-back pain. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000261. [abstract]
  13. Pengel LH, Herbert RD, Maher CG, et al; Acute low back pain: systematic review of its prognosis. BMJ. 2003 Aug 9;327(7410):323. [abstract]

Internet and further reading Acknowledgements EMIS is grateful to Dr Richard Draper for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 693
Document Version: 24
DocRef: bgp1073
Last Updated: 16 Oct 2008
Review Date: 16 Oct 2010

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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