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Low Back Pain, Red flags:
Weakness of legs/feet
Urinary retention
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Low Back Pain
Management
Red flag symptoms: admit or refer urgently for specialist assessment/imaging using clinical judgement
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Non-specific low back pain: assess for modifiable risk factors using a risk stratification tool such as STarT Back
Look at quality of life, pain severity, function and psychological distress for guiding management
Offer self-management advise eg addressing any specific concerns or treatment expectation, provide information on self-help measures to relieve symptoms such as exercises, and encouragement to stay active, resume normal activities and return to work as soon as possible.
Offer analgesia to manage pain: NSAID (Ibuprofen or Naproxen first line) alongside gastroprotective treatment, or Codeine with or without Paracetamol (if NSAIDs ineffective or not tolerated)
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If muscle spasms are present a short course of Benzodiazepine (such as Diazepam 2mg up to 3 times daily for 5 days) if no contraindications.
If at higher risk of poor outcome: offer referral to exercise programme, consider offering physiotherapist referral for manual therapy, consider offering referral for CBT if there is significant psychosocial obstacles to recover from, promote and facilitate returning to work.
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Diagnosis
Assessment of symptoms: Type of pain, duration of symptoms, aggravating and relieving factors, associated symptoms, radiation of pain and night pain.
Examination: Observe gait, posture, skin and any bruising, skin changes, rashes, deformity, or swelling of the back.
Neurological examination: look for loss of sensation, changes to reflexes, limitation of range of movement including straight leg raising, tenderness and fever.
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Diagnosis
Sciatica: Unilateral leg pain radiating below the knee to the foot or toes, low back pain (if present, its less severe than the leg pain), numbness, tingling and muscle weakness in the distribution of a nerve root (dermatome).
Osteoporosis: Non-specific pain, or localised tenderness, presence of risk factors for osteoporosis (female, advancing age, current or previous smoking history, use of corticosteroids).
Ankylosing spondylitis: Pain at night not relieved when supine, stiffness in the morning that is relieved by movement/exercise, gradual onset of symptoms, symptoms that have lasted more than three months.
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Intra-abdominal pathology causes: Gastrointestinal (peptic ulcer, pancreatitis), Genitourinary (Kidney stones, pyelonephritis, prostatitis or pelvic infection).
Non-specific lower back pain: Pain varies with posture and time, and is exacerbated by movement.
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Red Flags
Spinal Fracture:
- Sudden onset of severe central spinal pain which is relieved by lying down.
- History of major trauma (eg RTA, fall from height), minor trauma, or even just a strenuous lift in people with osteoporosis or those who use corticosteroids.
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
- There ma be a point of tenderness over a vertebral body.
Cancer;
- Age 50 years or older.
- Gradual onset of symptoms
- Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (eg at stool, coughing or sneezing) and thoracic pain
- Localised spinal tenderness
- No symptomatic improvement after four to six weeks of conservative low back pain therapy
- Unexplained weight loss
- PMH of cancer (breast, lung, GI, prostate, renal, and thyroids are more likely to metastasize to the spine)
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 (cause by loss of sensation when passing urine).
- Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
- Perianal or perineal sensory loss (saddle anaesthesia or parasthesia)
- Unexpected laxity of the anal sphincter.
Infection:
- Fever
- Tuberculosis, or recent urinary tract infection
- Diabetes
- History of intravenous drug use
- HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised
Low back pain is pain in the lumbosacral area of the back, between the bottom of the ribs and the top of the legs.
- Specific causes of low back pain include sciatica, vertebral fracture, intra-abdominal pathologies, and more rarely ankylosing spondylitis, cancer and infection.
- Non-specific low back pain is diagnosed when the pain cannot be attributed to a specific cause, although in many cases, may be related to trauma, or musculoligamentous strain.
Red flags:
- Weakness of legs/feet
- Urinary retention
- Urinary incontinence
- Faecal incontinence
- Saddle anaesthesia or parasthesia
- Loss of control of bowel
- Sudden spinal pain relieved by lying down
- History of trauma
- Structural deformity
- Point of tenderness over a vertebrae
- Age > 50
- Gradual onset
- Pain waking from/disturbing sleep
- Localized tenderness
- No improvement after 4-6 weeks treatment
- PMH Cancer
- Fever
- TB or recent UTI
- Diabetes
- Immunosuppressants/immunocompromised