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Mechanical Lower Back Pain (Clinical Presentation (Episodes are…
Mechanical Lower Back Pain
Key Facts
It is often traumatic or work related
Need to be alert to SINISTER CAUSES of back pain e.g. malignancy, infection of inflammatory causes
Back pain is very common, and often self-limiting
Red flags for possible SERIOUS SPINAL PATHOLOGY
Systemic steroids, drug abuse or HIV
Systemically unwell, weight loss
Thoracic pain
Persisting severe restriction of lumbar flexion
Constant, progressive, non-mechanical pain
Widespread neurology
Structural deformity
Violent trauma e.g. fall from height or road traffic accident
Age of onset LESS than 20 or GREATER than 55 yrs
Epidemiology
Common back pain in young people - 20-55yrs
Associated with heavy manual handling, stooping and twisting whilst lifting, exposure to whole body vibration, psychosocial distress, smoking and dissatisfaction with work
Main Causes
Spondylolisthesis
Heavy manual handling
Fractures
Stooping and twisting whilst lifting
Osteoarthritis
Exposure to whole body vibration
Lumbar disc prolapse
Risk Factors
Smoking & dissatisfaction with work
Risk factors for recurrent back pain
Increasing age
Pre-existing chronic widespread pain - fibromyalgia
Female
Psychosocial factors e.g. high levels of psychological distress, poor self-rated health and dissatisfaction with work
Psychosocial distress
Clinical Presentation
Episodes are generally short-lived and self-limiting - but once had one there is a significantly increased risk of further back pain episodes
Sudden onset
Pain is often unilateral and helped by rest
Pain worse in the evening
Muscular spasm is visible and palpable and causes local pain and tenderness - lessens when sitting or lying
Morning stiffness is absent
Back is stiff and a scoliosis (where spine twists and curves to a side) may be present when patient is standing
Exercise aggravates pain
Pathophysiology
Any of these structures may be a source of pain
Some typical syndromes are recognised:
Facet joint syndrome - lumbar spondylosis also causes secondary osteoarthritis of the misaligned facet joints
Fibrositic nodulous - causes unilateral or bilateral low back and buttock pain
Postural back pain and sway back of pregnancy - low back pain is common in pregnancy and reflects altered spinal posture and increased ligamentous laxity
Lumbar spondylosis - main lesion occurs in an intervertebral disc
Spinal movement occurs at the disc and the posterior facet joints - stability is normally achieved by a complex mechanism of spinal ligament and muscles
Differential Diagnosis
In elderly - ESR and CRP will distinguish mechanical back pain form polymyalgia rheumatics (PMR)
Diagnosis
MRI more preferable than CT (better for bone pathology)
Bone scans
Spinal X-rays - only for red flags
Worse at night or in the morning, when an inflammatory arthritis
Associated with systemic illness, fever or weight loss
Persistent and a serious cause is suspected
Is associated with neurological symptoms or signs
Starts before age of 20 or over 50
Treatment
Acupuncture helps some
Excessive rest AVOIDED
Combined with physiotherapy, back muscle trainmen regimens and manipulation
Re-education in lifting and exercises to prevent further attacks of pain
Analgesia e.g. paracetamol, NSAIDs to allow normal mobility
Comfortable sleeping position using a mattress of medium (not hard) firmness
Urgent neurosurgical referral if any neurological deficit