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Back pain: Low back pain affects the lumbosacral area of the back, between…
Back pain: Low back pain affects the lumbosacral area of the back, between the bottom of the ribs and the top of the legs
Causes
Specific causes include sciatica, vertebral fracture, intra-abdominal pathologies, and more rarely, ankylosing spondylitis, cancer, and infection.
Non specific causes is diagnosed when the pain cannot be attributed to a specific cause, although in many cases, may be related to trauma, or musculoligamentous strain.
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management
Assess persons QOL, pain, severity, function and most important factors to guide management
people with low back pain likely to improve quickly require less intensive support. people at higher risk of poor outcome require more complex and intensive support
Non specific back pain
Analgesia - NSAIDs if no contraindications consider GI cover (ibuprofen or naproxen lowest possible dose)
If NSAIDS contraindicated -offer codeine with or without paracetamol, taking into account the risk of opioid dependence and adverse effects such as constipation.
Self Mx - normal activities. Information leaflets on simple exercises, may help relieve symptoms e.g backcare. Local heat may relieve pain and reduce muscle spasm
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non specific low back pain suspected assess using risk stratification tool STar TBack to identify modifiable risk (biomedical, psychological or social)
referral
Offer referral for a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches). Take the person's specific needs, preferences and capabilities into account when choosing the type of exercise.
Consider offering referral to a physiotherapist for manual therapy (spinal manipulation, mobilisation, or massage) as part of a treatment package including exercise.
Consider offering referral for cognitive behavioural therapy as part of a treatment package including exercise, with or without manual therapy, if the person has significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition), or when other treatments have not been effective
If there are Red flag symptoms and signs that may suggest a serious underlying cause, admit or refer urgently for specialist assessment, or imaging, using clinical judgement.
Consider arranging specialist referral:
If there is progressive, persistent, or severe neurological deficit, consider admission or refer urgently to neurosurgery or orthopaedics for specialist assessment, depending on clinical judgement and local referral pathways.
Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when non-surgical treatment has not worked, and the main source of pain is thought to come from structures supplied by the medial branch nerve, and the person's pain is rated as 5 or more on a visual analogue scale, or equivalent, at the time of referral.
Prognosis
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high risk of long term pain and physical disability are people with pain lasting more than 12 weeks, psychosocial distress,maladaptive coping strategies, excessive negative thoughts to cope with pain
Red Flags
Cauda equina syndrome .
Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine).
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Cancer of the spine
50 years and over,gradual onset of symptoms, unexplained weight loss, pmhx cancer, localised spinal tenderness, no improvement after 4-6 weeks of conservative mx
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
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Spinal infection.
fever, TB, recent UTI, Hx IVDA, diabetes, HIV or immunocompromised
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Diagnosis
SOCRATES assessment of pain, night pain
examine gait, posture, skin, deformity or swelling back
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Low back pain can be caused by Intra-abdominal pathology- GI causes: peptic ulcer or pancreatitis. GU- kidney stones, pyleonephritis, pelvic infection
Consider OP, sciatica, ankylosing spondylitis