BACK PAIN - Clinical features, Investigations

Lumbar back pain

Lumbar back pain is a common symptom experienced by most people at some time in their lives. Only a few patients have a serious underlying dis-order. Mechanical back pain is a common cause in young people. It starts suddenly, is often unilateral, and may be helped by rest. It may arise from the facet joints, spinal ligaments or muscle. The history, physical examination and simple investigations will also often identify the minority of patients with other causes of back pain (Table 7.2).

The age of the patient helps in deciding the aetiology of back pain because certain causes are more common in particular age groups. These are illus-trated in Table 7.3.

Table 7.2 Causes of lumbar back pain

Causes

History and examination

Mechanical

Lumbar disc prolapse
Osteoarthritis
Fractures
Spondylolisthesis
Spinal stenosis

Often sudden onset
Pain worse in the evening
Morning stiffness is absent
Exercise aggravates pain

Inflammatory

Ankylosing spondylitis
Infection (see below)

Gradual onset Pain worse in the morning Morning stiffness is present Exercise relieves pain

Serious causes

Metastases

Multiple myeloma

Tuberculosis osteomyelitis

Bacterial osteomyelitis

Spinal and root canal stenosis

Age <20 or >50 years

Constant pain without relief

History of TB, HIV, carcinoma, steroid use

Systemically unwell: fever, weight loss

Localized bone tenderness

Bilateral signs in the legs

Neurological deficit involving more than one root level

Bladder, bowel or sexual function deíicits

Others

Osteomalacia, Paget’s disease, referred pain from pelvic abdominal disease

Text in red indicates the ‘red flags’ in a patient with lumbar back pain. Onset of thoracic pain is also a ‘red flag’.

 

Table 7.3 Low back pain - disorders most commonly found in specific age groups

15-30 years

30-50 years

50 years and over

Mechanical

Mechanical

Degenerative joint disease

Prolapsed

Prolapsed intervertebral

Osteoporosis

intervertebral disc

disc

Paget’s disease

Ankylosing spondylitis

Degenerative joint disease

Malignancy

Spondylolisthesis

Malignancy

Myeloma

  Fractures (all ages)  
  Infective lesions (all ages)  

Investigations

A detailed history and physical examination (Table 7.2) will lead to the diag-nosis in many cases. The key points are age, speed of onset, the presence of motor or sensory symptoms, involvement of the bladder or bowel, and the presence of stiffness and the effect of exercise. Young adults with a history suggestive of mechanical back pain and with no physical signs do not need further investigation.

■ Full blood count, ESR and serum biochemistry (calcium, phosphate, alka-line phosphatase) are required only when the pain is likely to be due to malignancy, infection or a metabolic cause. Prostate-specific antigen should be measured if secondary prostatic disease is suspected.

■ Spinal X-rays are only indicated if there are ‘red flag' symptoms and signs (Table 7.3) which indicate a high risk of more serious underlying problems.

■ Bone scans (p. 274) show increased uptake with infection or malignancy.

■ MRI is useful when neurological symptoms and signs are present. It is useful for the detection of disc and cord lesions. Computed tomography (CT) scans demonstrate bone pathology better.

Management

The treatment depends on the cause. Mechanical back pain is managed with analgesia, brief rest and physiotherapy. Patients should stay active within the limits of their pain. Exercise programmes reduce long-term problems.

Intervertebral disc disease

Acute disc disease

Prolapse of the intervertebral disc results in acute back pain (lumbago), with or without radiation of the pain to areas supplied by the sciatic nerve

(sciatica). It is a disease of younger people (20-40 years) because the disc degenerates with age and in elderly people is no longer capable of prolapse. In older patients sciatica is more likely to be the result of compression of the nerve root by osteophytes in the lateral recess of the spinal canal.

Clinical features

There is a sudden onset of severe back pain, often following a strenuous activity. The pain is often clearly related to position and is aggravated by movement. Muscle spasm leads to a sideways tilt when standing. The radiation of the pain and the clinical findings depend on the disc affected (Table 7.4), the lowest three discs being those most commonly affected.

Investigations

Investigations are of very limited value in acute disc disease and X-rays are often normal. MRI is usually reserved for patients in whom surgery is being considered (see later).

Management

Treatment is aimed at the relief of symptoms and has little effect on the duration of the disease. In the acute stage, treatment consists of bed rest on

Table 7.4 Symptoms and signs of common root compression syndromes produced by lumbar disc prolapse

Root

lesioii

Pain

Sensory

loss

Motor

weakness

Reflex

lost

Other

signs

S1

From buttock down back of thigh and leg to ankle and foot

Sole of foot and

posterior

calo

Plantar flexion of ankle and toes

Ankle

jerk

Diminished straight leg raising

L5

From buttock to lateral aspect of leg and dorsum of foot

Dorsum of foot and
anterolateral aspect of lower leg

Dorsiflexion of foot and toes

None

As above

L4

Lateral aspect of thigh to medial side of calf

Medial
aspect of
calf and
shin

Dorsiflexion and inversion of ankle; extension oo knee

Knee

jerk

Positive femoral stretch test

a firm mattress, analgesia, and occasionally epidural corticosteroid injection in severe disease. Surgery is only considered for severe or increasing neurological impairment, e.g. foot drop or bladder symptoms. Physiotherapy is used in the recovery phase, helping to correct posture and restore movement.

Chronic disc disease

Chronic lower back pain is associated with ‘degenerative' changes in the lower lumbar discs and facet joints. Pain is usually of the mechanical type (see above). Sciatic radiation may occur with pain in the buttocks radiating into the posterior thigh. Usually the pain is long-standing and the prospects for cure are limited. However, measures that have been found useful include NSAIDs, physiotherapy and weight reduction. Surgery can be considered when pain arises from a single identifiable level and has failed to respond to conservative measures, and fusion at this level, with decompression of the affected nerve roots, can be successful.

Mechanical problems

Spondylolisthesis

Spondylolisthesis is characterized by a slipping forward of one vertebra on another, most commonly at L4/L5. It arises because of a defect in the pars interarticularis of the vertebra, and may be either congenital or acquired (e.g. trauma). The condition is associated with mechanical pain which worsens throughout the day. The pain may radiate to one or other leg and there may be signs of nerve root irritation. Small spondylolistheses, often associated with degenerative disease of the lumbar spine, may be treated conservatively with simple analgesics. A large spondylolisthesis causing severe symptoms should be treated with spinal fusion.

Spinal stenosis

Narrowing of the lower spinal canal compresses the cauda equina, resulting in back and buttock pain, typically coming on after a period of walking and easing with rest. Accordingly it is sometimes called spinal claudication. Causes include disc prolapse, degenerative osteophyte formation, tumour and congenital narrowing of the spinal canal. CT and MRI will demonstrate cord compression, and treatment is by surgical decompression.

Neck pain

Disc disease, both acute and chronic, the latter in association with osteo-arthritis, may occur in the neck as well as in the lumbar spine. The three lowest cervical discs are most often affected, and there is pain and stiffness of the neck with or without root pain radiating to the arm. Chronic cervical disc disease is known as cervical spondylosis.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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