Approach to the patient

with Back pain

D
Objectives
Diagnosis including history, Red Flags, and Examination
Brief comment on Mechanical, Inflammatory, Root nerve
compression, and Malignancy
Common causes
Role of primary health care in management
When to refer to a specialist
Prevention and Education
In USA it is the commonest cause of limitation of activity in
those under the age of 45. (1)

The lifetime prevalence of non-specific (common) low back pain

is estimated at 60–70% (1)
 53.2 79.2%
%

In Saudi Arabia Seven studies were cross-sectional and

found a prevalence and pattern ranging from 53.2% to
79.17%. (2)
Role play
MCQs!
1- Which of the following is not indicative of inflammatory
back pain? (3)

a. Insidious onsetb. Onset before 40 years of age

c. Pain for more than 3 monthsd. Morning stiffnesse. Aggravation of pain with
activity

https://PollEv.com/surveys/kPSMW0SBL/web
2- Which of the following is (are) characteristic of a history
of mechanical Lower Back Pain? (3)

a. Relatively acute onsetb. History of overuse or a precipitating injury

c. Pain worse during the dayd. All
3- Which of the following is (are) a "red flag(s)" or danger
signal(s) relative to the diagnosis of LBP? (3)

a. Coughb. Impotence
c. Chest paind. Constipation
4- What is the most cost-effective and crucial aspect of the
treatment of chronic LBP? (3)

a. Patient educationb. Physiotherapy

c. Bed restd. Morning stiffness
5- Which of the following is the most common cause of LBP?
(3)

a. Metastatic bone diseaseb. Inflammatory back pain

c. Lumbosacral sprain or straind. None of the above
What is the diagnostic approach to a
patient with back pain?

A thorough history and physical examination

helps elucidate the diagnosis in most patients.
 Hx taking (4)

Doctor I have PAIN!

 DDx
Mechanical Systemic Referred
Lumbar strain or sprain Malignancy Acute Aneurysm

Herniated disc and spinal Multiple myeloma Pelvic disease

stenosis
Metastatic carcinoma Prostatitis/Endometriosis
Degenerative processes
of disc and facet joint
Infection Renal disease

Compression fracture Osteomyelitis Stones / Pyelonephritis

Spondylolysis TB GI disease

Brucellosis Pancreatitis

Inflammation Cholecystitis
Ankylosing
spondylitis
 1 Personal Data
2 SOCRATES

3 Neurological?
4 Red Flags!
5 PMH
Hx taking
6 Past Surgical Hx
7 Medications
8 Family, Social & Systemic Review
 1 Personal Data

Age? Residence?
Occupation?

2 SOCRATES
Site? Associated?
Hx taking

Onset? Timing?
Character? Exacerbating?

Radiation? Severity?
 3 Neurological?

4 Red Flags!

Hx taking

Warrant additional
 5 PMH
Trauma? Cancer? Psychatic?

6 Past Surgical Hx
7 Medications
Steroid?
Hx taking

8 Family, Social & Systemic Review

Inherited disease? Smoking? Alcohol?

Social?
 One More thing
Idea Concern Expectation

How does it affect him/her Emotionally/Functionally

Hx taking
Physical Examination
Will be explained by Gassan in latter slides

Laboratory tests
Not necessary in the evaluation of back pain unless the concerned
about the possibility of malignancy or infection (5)

FBC, ESR, C-reactive protein (CRP), and blood cultures

Urinalysis and Culture.. Why?

Imaging
High-risk patients

Most patients with low back pain with or without sciatica do not
routinely require imaging when presenting in a non-specialist
setting. (5)

Reassure.. that their symptoms will respond

to conservative treatment. (5)
If symptoms persist longer than 6 to 8 weeks,
plain x-rays should be obtained at that
time (5)
Imaging
MRI or CT, only if: neurological compromise, infection, or tumors is
considered (5)

After discussion with a spinal surgeon.

MRI is the preferred study. If contraindicated a CT myelogram is

usually warranted.(5)

In trauma situations, the standard AP pelvis and cervical spine

radiographs should be obtained. (5)
Imaging (6)

Do not routinely offer imaging in a non-specialist setting.

Explain to the patient that if she/he is being referred for specialist
opinion, she/he may not need imaging.
Consider imaging for people with low back pain with or without
sciatica only if the result is likely to change management.
 Case
A 38-year-old man with no significant history of back pain
developed acute LBP when lifting boxes 2 weeks ago.
The pain is aching in nature, located in the left lumbar area, and
associated with spasms. He describes previous similar episodes
several years ago, which resolved without seeing a doctor.
He denies any leg pain or weakness. He also denies fevers, chills,
weight loss, and recent infections
On examination, there is decreased lumbar flexion and extension
secondary to pain, but a neurologic exam is unremarkable.

Mechanical Inflammation Malignancy Root Nerve Compression

 Case
A 20-year-old man presents to his primary care physician with low
back pain and stiffness that has persisted for more than 3 months.
There is no history of obvious injury but he is a very avid sportsman.
His back symptoms are worse when he awakes in the morning, and
the stiffness lasts more than 1 hour. His back symptoms improve with
exercise. He has a desk job and finds that sitting for long periods of
time exacerbates his symptoms.
His back symptoms also wake him in the second half of the night. He
normally takes an anti-inflammatory drug during the day, and finds
his stiffness is worse when he misses a dose. He has had 2 bouts of
iritis in the past.

Mechanical Inflammation Malignancy Root Nerve Compression

 Case

9-year-old male patient who had a history of low back pain for about
a year and was reporting severe, constant, and aching lower back pain
of 8-9 on a scale of 10.
as well as radicular right leg pain, decreased sensation on the right,
difficulty straightening his right leg making it difficult to walk.
An MRI showed a rather large L5-S1 herniated disc on the right side
with severe degenerative disc disease.

Mechanical Inflammation Malignancy Root Nerve Compression

 Case

A man aged 78 years presented to his general practitioner with

new-onset low back pain. The patient had metastatic prostate
cancer, which was diagnosed 2 years ago.
He reported a 6-week history of constant, burning pain in the
lower lumbar region, which was worse at night and was 7/10 in
severity on the Numeric Pain Rating Scale.
He had no relief with regular paracetamol or ibuprofen. He had
not had lower limb weakness, numbness, lower urinary tract
symptoms or weight loss.

Mechanical Inflammation Malignancy Root Nerve Compression

Mechanical
Tends to get better or worse depending on your position – for example, it
may feel better when sitting or lying down.
Typically feels worse when moving
Can develop suddenly or gradually
Might sometimes be the result of poor posture or lifting something awkwardly,
but often occurs for no apparent reason
May be due to a minor injury
Inflammation
Age at onset of back pain <45 years
Back pain lasting > 3 months
Night pain
Early morning pain and stiffness lasting more than one hour
Insidious onset
Tenderness/inflammation over the joint
Increased by Rest and Relived by activity
Root Nerve Compression
Characterized by radicular pain
arising from nerve root impingement
due to herniated discs.
Radicular pain: Pain that radiates into
the lower extremity directly along the
course of a spinal nerve root.
Malignancy
Metastatic tumors are found mostly in patients older than 50 years .
Metastatic disease is more common than primary tumors of the spine, and
thoracic spine metastatic lesions are more common than lumbar
Patient usually has constitutional symptoms such as fever ,Wight loss,
loss of appetite and N\V
 Others
Pediatrics:
In Primary care settings most of the cases are due to
overloaded school backpacks.. (10)
Also think about psychological causes to avoid going to
school.
Women:
Ask about pregnancy.
Psychiatric patients: 75% of Depressed patients present with
pain .. One of the most common sites is Lower back pain (11)
Case
A 28-year-old man with chronic low back pain (LBP) comes to
your office for renewal of his medication. He was injured at work 5
years ago while attempting to lift a box of heavy tools. Since that
time, he has been off work, living on compensation insurance
payments, and he has not been able to find a job that does not
aggravate his back.
On physical examination, the patient demonstrates some vague
tenderness in the paravertebral area around L3 to L5. He has some
limitations on both flexion and extension.
What is the most likely
diagnosis?
What is the next
step?
Lumbar muscular strain/sprain
Stiffness, and/or soreness of the lumbosacral region (underneath the
twelfth rib and above the gluteal folds) persisting for <12 weeks. (12)

What is the difference between strain and sprain?

Strains occur when a muscle is stretched too far and tears,

damaging the muscle itself.
Sprains happen when over-stretching and tearing affects
ligaments, which connect the bones together.
Lumbar muscular strain/sprain
The most common source of back pain but do not sound serious and do
not typically cause long-lasting pain.

Arises from any combination of pathology involving discs, vertebrae,

facet joints, ligaments, and/or muscles.
 Lumbar muscular strain/sprain
Clinical presentation: Sharp intense pain for 1 to 2 days; muscle spasm;
most patients recover within 3 months

Risk factors?
1. Lifting a heavy object, or twisting the spine while lifting
2. Sudden movements that place too much stress on the low back, such as a
fall
3. Poor posture over time
4. Sports injuries, especially in sports that involve twisting or large forces of
impact
Lumbar muscular strain/sprain
Benign physical examination.

<4 Weeks >6 Weeks

Investigations?
(12)
Clinical diagnosis Lumbar Spine X-Ray
Lumbar Spine MRI
Lumbar Spine CT
Labs
Management:
What is the aim of the treatment?
Reducing pain and restoring functional status.
 Lumbar muscular strain/sprain
Management:(12)

Evidence B

Evidence Evidence C
B
Lumbar muscular strain/sprain
Management:
For the Muscle relaxant:
NSAIDs if the first line. (Cochrane)
Paracetamol (Evidence C)
Case

38 year old laborer who had the immediate onset of left leg
burning pain and weakness after lifting a heavy load. He had
onset of some bladder incontinence

What is the most likely

diagnosis?
What is the next
step?
Herniated nucleus pulposus (HNP)
A complex, multi-factorial,
clinical condition characterized
by low back pain with or
without the concurrence of
radicular lower limb symptoms
in the presence of
radiologically-confirmed
degenerative disc disease.
The pain is exacerbated by
activity, but may be present in
certain positions, such as sitting.
Herniated nucleus pulposus (HNP)
Radiating lower extremity pain in a dermatomal distribution;
History of bowel or bladder dysfunction, bilateral sciatica, and saddle
anesthesia may be symptoms of severe compression of the cauda equine

Positive straight-leg raise or contralateral straight leg (reproduced below

60° of hip flexion); positive femoral stretch test may suggest upper
lumbar disc herniation.
Herniated nucleus pulposus (HNP)
Causes:
Complex mechanical and inflammatory process.
Genetic influences have been found to be more important than the
mechanical effects.
Associated with increasing age, smoking, the presence of facet joint
tropism and arthritis, abnormal pelvic morphology, and changes in sagittal
alignment.
Herniated nucleus pulposus (HNP)
Investigations:
MRI: herniated disc

Management:
Saddle (perineal) anaesthesia, sphincter
dysfunction, bladder retention, and leg
weakness = Cauda Equina Syndrome
(CES)
Urgent referral to the
hospital.
Emergency decompression of the spinal
canal within 48 hours after the onset of
symptoms
Herniated nucleus pulposus (HNP)
Management:
Case
A 63-year-old woman presents with low back pain and cramping in both
posterior thighs and numb- ness radiating into the feet with ambulation.
It wors- ens with standing and walking and improves with sit- ting and
bending forward. She has no bowel or bladder complaints.
On examination, she has full strength, normal sensation, reflexes are
symmetric, and she has 2+ peripheral pulses. Straight leg raise is
negative. What is this patient’s most likely diagnosis?

What is the most likely

diagnosis?
What is the next
step?
 Spinal stenosis
Lumbar spondylosis refers to
degenerative conditions of the lumbar
spine that narrow the spinal canal,
lateral recesses, and neural foramina.
Facet joint and ligamentous
hypertrophy, intervertebral disc
protrusion, and spondylolisthesis may
all contribute to the stenosis, and
symptoms result from neural
compression of the cauda equina,
exiting nerve roots, or both.
 Spinal stenosis
Intermittent pain radiating to the thigh or legs.
Worse with prolonged standing, activity, or lumbar extension.
Pain is typically relieved by sitting, lying down, and/or lumbar flexion;
patient may describe intermittent burning, numbness, heaviness, or
weakness in their legs, unilateral or bilateral radicular pain, motor deficits,
bowel and bladder dysfunction, and back and buttock pain with standing
and ambulation
 Spinal stenosis
Patients walk with a forward flexed gait; patients with vascular
claudication have diminished pulses and typical skin changes, such as
mottled discoloration, thinning and shiny skin
 Spinal stenosis
Investigations:
MRI:
 Spinal stenosis
Management:
 Spinal stenosis
Management:

Non Pharmaceutical measures:

Temporary reduction in physical activity is recommended; patients
should be careful to avoid bending, lifting, or twisting movements until
the pain subsides.
Bed rest is not recommended.
Prolonged bed rest (>4 days) is contra-indicated, especially in older
patients as it may lead to rapid de-conditioning and increased risk of
DVT.
Almost done ☹
Case

A 70-year-old man, 6 months after renal transplantation and

on corticosteroid treatment, presents with severe back pain. X-
ray evaluation of the thoracic and lumbar spine discloses
evidence of multiple vertebral compression fractures.

What is the most likely

diagnosis?
What is the next
step?
Compression fracture
Most osteoporotic spinal compression fractures
represent an isolated failure of the anterior
spinal column due to a combination of flexion
and axial compression loading.
The stability of the spine is not compromised
with this type of fracture. These fractures are
traditionally considered benign injuries that
heal without complications.
Compression fracture
Typically history of trauma, although acute event not always recalled;
pain at rest and at night, previous history of fractures (e.g., distal radius,
hip or other vertebral compression fractures)

Tenderness to palpation over the midline; increased kyphosis, normal

neurological examination unless there is retropulsion of bone into the
neural elements, such as in burst fractures
Compression fracture
plain x-rays:

MRI?
Useful in distinguishing between osteoporotic
compression fractures and those caused by
underlying tumour or infection.
Compression fracture
Management:
1st: Limited bed rest.
Adjunctive: Analgesia (Paracetamol/NSAIDs)
Examination
look, feel, move and test function.

You should perform a physical examination to reproduce the patient’s

symptoms and localized the level of lesion. (7)(14)(15)
Components of physical examination
1- Inspection:
Position
Exposure
Look for deformity, inspecting from both the back and the side.
Note especially loss of the normal thoracic kyphosis and lumbar lordosis, which
is typical of ankylosing spondylitis.
Also note any evidence of scoliosis, a lateral curvature of the spine that may be
simple (‘C’ shaped) or compound (‘S’ shaped)
soft-tissue abnormalities like a hairy patch or lipoma that might overlie a
congenital abnormality, e.g. spina bifida.
Muscle wasting
shoulders & pelvis level. (7)(14)(15)
Components of physical examination
2- Palpation
Patient should be in prone position.
Palpation occurs:
1. centrally
2. unilateral
3. Soft tissues
4. After warning the patient, lightly percuss the spine with your closed fist and note any
tenderness. (7)(14)(15)
 Components of physical examination
3- Active movements:
There are three main movements of the lumbar spine:
1. Flexion
2. Extension
3. Lateral bending
4. Rotation (7)(14)(15)(16)
Components of physical examination
4- provocative tests
Femoral stretch test:
1. Knee flexion hip extension while the patient is lying in
prone position.
2. Positive if pain felt in ipsilateral anterior thigh.
3. Positive test mean that the L3 and L4 nerve roots are
involved. (7)(14)(15)
Components of physical
examination
Straight leg raising (SLR) test
1. Done while the patient lying in supine position.
2. Tension increased by dorsiflexion of foot (Bragard’s test). Root
tension relieved by flexion at the knee.
3. Pressure over centre of popliteal fossa causes pain locally and
radiation into the back.
4. Positive test mean that the L4, L5 and S1 nerve roots are involved.
(7)(14)(15)
Components of physical examination

5- Neurological testing of lower limbs

Do Neurological examination if patient has any signs or symptoms of nerve root
compression.

If there is nerve roots compression patient will have pain, pareasthesia, anesthesia
and weakness, extend into the leg. (7)(14)(15)
Main nerve roots
A- L1:
Motor  Hip flexion(psoas major)
Sensation around the groin and hip area
Reflex  cremasteric relfex (L1,L2)

B- L2:
Motor  Hip flexion
Sensation anterior thigh
Reflex  knee jerk (L2,L3, L4)(7)(14)(15)
Main nerve roots
C- L3
Motor  extension of knee
Sensation  anterior thigh
Reflex  knee jerk (L3, L4)

D- L4
Motor  ankle dorsiflexion and foot inversion.
Sensation  inner border of foot to great toe
Reflex  knee jerk(7)(14)(15)
Main nerve roots
E- L5
Motor: walking on heels (ankle dorsiflexion), extension of
great toe
Sensation  middle three toes (dorsum)
Reflex  nil

F- S1
Motor: walking on toes (ankle planter flexion), foot eversion
Sensation  little toe, most of sole
Reflex  ankle jerk (S1, S2)(7)(14)(15)
X-Ray

Normal lumbar spine radiographs. A: AP projection. B: Lateral projection.

X-Ray

Metastatic prostate cancer

MRI

Normal MRI
MRI

Degenerative disease
Role of PHC:
Educate patient about the natural history of back pain.
Ask about and address the patient’s concerns and goals. (patient centered care)
Maximize functional status.
Relief the pain.
Improve associated symptoms, such as sleep or mood disturbances or fatigue.
Referral of complicated cases.
Prevention heavy lifting, socio-demographic factors such as smoking and obesity
Primary care services have an approach to risk stratification for young people and adults presenting with a new episode of low
back pain with or without sciatica.
Young people and adults with low back pain with or without sciatica are given advice and information to self-manage their
condition. (6)
When to refer ?
Urgent/Emergency referrals :
1. Cauda equina
2. Sever radiculopathy.
3. Fractures.
Other referrals
1. Recalcitrant spinal canal stenosis
2. Neoplasia or infection
3. Undiagnosed back pain
4. Paget disease
5. Continuing pain of 3 months’ duration without a clearly definable
cause(16)
 Prevention and education
Losing weight: too much upper body weight can strain the lower back .
Posture: How you sit, stand and lie down can have an important effect on your back. The following tips
should help you maintain a good posture.

Standing: Stand upright, with your head facing forward and your back straight. Balance your weight evenly on
both feet and keep your legs straight
Prevention and education
Sitting and driving:
Sit up with your back straight and your shoulders back. Your knees and hips should be level and your feet
should be flat on the floor.
Prevention and education
Sleeping:
Your mattress should be firm enough to support your body while supporting the weight of your shoulders and
buttocks, keeping your spine straight.
Prevention and education
Lifting and carrying:
One of the biggest causes of back injury is lifting or handling objects incorrectly.
Think before you lift:
can you manage the lift?
Push rather than pull – if you have to move a heavy object across the floor, it is better to push it rather than pull it.
Prevention and education
Exercise:
Exercise is both an excellent way of preventing back pain and of reducing it, but should seek medical
advice before starting an exercise programs if you've had back pain for six weeks or more.
Role play
1- Which of the following is not indicative of inflammatory
back pain?

a. Insidious onsetb. Onset before 40 years of age

c. Pain for more than 3 monthsd. Morning stiffnesse. Aggravation of pain with
activity

https://PollEv.com/surveys/kPSMW0SBL/web
2- Which of the following is (are) characteristic of a history
of mechanical Lower Back Pain?

a. Relatively acute onsetb. History of overuse or a precipitating injury

c. Pain worse during the dayd. All
3- Which of the following is (are) a "red flag(s)" or danger
signal(s) relative to the diagnosis of LBP?

a. Coughb. Impotence
c. Chest paind. Constipation
4- What is the most cost-effective and crucial aspect of the
treatment of chronic LBP?

a. Patient educationb. Physiotherapy

c. Bed restd. Morning stiffness
5- Which of the following is the most common cause of LBP?

a. Metastatic bone diseaseb. Inflammatory back pain

c. Lumbosacral sprain or straind. None of the above
References
1. Hengel KM, Visser B, Sluiter JK. The prevalence and incidence of
musculoskeletal symptoms among hospital physicians: A systematic review.
International Archives of Occupational and Environmental Health.
2011;84(2):115-9.
2. Awaji M. Epidemiology of Low Back Pain in Saudi Arabia. J Adv Med
Pharm Sci [Internet]. 2016;6(4):1–9. Available from:
http://sciencedomain.org/abstract/13544
3. Swanson’s Family Medicine Review (7th Ed.)

4. Henderson M, Tierney L, Smetana G. The patient history. New York:

McGraw-Hill Medical; 2012.
5. Assessment of back pain [Internet]. BMJ Best Practice; 2018 [cited 4
September 2018]. Available from:
https://bestpractice.bmj.com/topics/en-gb/189/pdf/189.pdf
References
6. Low back pain and sciatica in over 16s: assessment and management. NICE
guideline; 2016.
7. Evaluation of low back pain in adults [Internet]. Uptodate.com. 2018 [cited
4 September 2018]. Available from:
https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults?
search=evalu%20ation-of-low-back-pain-in
adults&source=search_result&selectedTitle=1~150&usage_type=default&dis
play_rank=1
8. Dog and Rooster I. Disc Herniation Case Studies| Spine Institute of San
Diego : Center for Spinal [Internet]. Sdspineinstitute.com. 2018 [cited 6
September 2018]. Available from: http://www.sdspineinstitute.com/case-
studies/disc-herniations/lumbar.html
9. Practitioners T. RACGP - Back pain in a cancer patient: a case study
[Internet]. Racgp.org.au. 2018 [cited 6 September 2018]. Available from:
https://www.racgp.org.au/afp/2014/august/back-pain-in-a-cancer-patient/
References
10. Evaluation of the child with back pain [Internet]. Uptodate.com. 2018
[cited 4 September 2018]. Available from:
https://www.uptodate.com/contents/evaluation-of-the-child-with-back-pain
11. Kleiber B, Jain S, Trivedi MH. Depression and Pain: Implications for
Symptomatic Presentation and Pharmacological Treatments. Psychiatry
(Edgmont). 2005;2(5):12-18.
12. Musculoskeletal lower back pain [Internet]. BMJ Best Practice. 2018
[cited 4 September 2018]. Available from:
https://bestpractice.bmj.com/topics/en-gb/778
13. Osteoporosis - Symptoms, diagnosis and treatment | BMJ Best Practice
[Internet]. Bestpractice.bmj.com. 2018 [cited 6 September 2018]. Available
from: https://bestpractice.bmj.com/topics/en-us/85/case-history
References
14. Talley Clinical Examination - 7th Ed

15. Macleod's Clinical Examination (13th Ed.)

16. Low back pain [Internet]. EBM Guidelines Available from:

http://www.ebm-guidelines.com/ebmg/ltk.free?p_artikkeli=ebm00435
Take Home Message
Back pain mostly diagnosed clinically.
Exclude the RED FLAGS
Don’t forget ICE
Imaging is not a must ‫يا ابني‬
Medications is not everything even ‫يا ابني‬
When you suspects Cauda Equine Refer!!
Not every patient deserve a complete rest..
Some are contraindicated.