Back pain - low (without radiculopathy)
Questionnaire/history: Site?
Onset?
Injury?
Characteristics? - Neurogenic claudication (pain getting better with leaning forward or sitting down)?
Radiation? - Unilateral leg pain?
- Bilateral leg pain?
- Bilateral buttock pain?
Night pain?
Pain intensity?
Exacerbating factors?
Relieving factors?
Associated symptoms?
- Numbness (eg perianal, perineal or genital sensory loss)?
- Weakness?
- Resent-onset urinary retention or overflow incontinence?
- Unexpected laxity of the anal sphincter?
- Resent onset faecal incontinence? - Sexual dysfunction?
- Unexplained weight loss?
- Other?
Past medical history?
Current medication?
Painkillers?
Drug allergies?
Examination:
Gait?
Tandem gait?
Posture?
Skin changes/bruising/rash?
Deformity (eg step deformity)?
Swelling?
Tenderness?
Limitation of range of movement (ROM)?
Weakness (0 = total paresis, 1 = palpable or visible contraction, 2 = active movement, gravity eliminated, 3 = active movement against gravity, 4 = active movement against some resistance, 5 = active movement against full resistance, NT = not testable)
- Elbow flexors (C5)?
- Wrist extensors (C6)?
- Elbow extensors (C7)?
- Finger flexors (distal phalanx of middle finger) (C8)?
- Finger abductors (little finger) (T1)? - Hip flexors (L2)?
- Knee extensors (L3)?
- Ankle dorsiflexors (L4)?
- Long toe extensors (L5)?
- Ankle plantar flexors (S1)?
Loss of anal tone (if indicated)?
Loss of sensation (ISNCSCI worksheet, 0 = absent, 1 = impaired, 2 = normal, NT = not testable)?
- Light touch?
- Pin prick?
- Light touch score? /112
- Pin prick score? /112
- Anal sensation (yes/no) (if indicated)?
Changes to reflexes?
- Biceps reflex (C5/6)?
- Triceps reflex (C7/8)?
- Patella reflex (L3/4)?
- Ankle reflex (S1/2)?
Any signs of brisk reflexes? If yes, myeolopathy signs?
- Inverted brachioradialis/supernator sign (tapping wrist/hand -> rapid finger flexion)?
- Hoffman's sign (flicking of nail of middle finger -> abduction of the thumb and flexion of the index finger)? - Clonus?
Radiculopathy signs?
- Straight leg raise (Lasegue) test?
Diagnosis:
Musculoskeletal affliction/idiopathic LBP?
Visceral (2%)?
- AAA?
- Genitourinary tract?
- Gastrointestinal tract?
Non-mechanical causes?
- Tumour (0.7%)?
- Inflammatory (0.3%)?
-- Ankylosing spondylitis?
-- Rheumatoid arthritis?
-- Psoriatic arthritis?
- Diffuse idiopathic skeletal hyperostosis (DISH)?
- Infection (0.01%)?
- Pagets?
- Osteochondrosis?
Mechanical causes?
- Degenerative (10%)?
- Spondylolysis/spondylolithesis (2%)
- Discogenic?
Radiculopathy?
- Spinal stenosis?
- Disc prolapse?
-- Cervica disc herniation?
-- Lumbar disc herniation?
-- Central disc herniation (Cauda Equina Syndrome)?
- Spondylolithesis?
-- Degeneration?
-- Isthmic spondylolytic?
Fracture?
Management:
According to cause, if musculoskeletal:
Advised:
- Ibuprofen or offered naproxen if no contraindications (with gastroprotective treatment) (+/- paracetamol)
- Codeine if nonsteroidal anti-inflammatory drugs (NSAIDs) contraindicated, not tolerated or ineffective
- Diazepam 2 mg up to three times a day for up to 5 days if muscle spasms
- Local heat
- A firm cushion between the knees when sleeping on the side, or several firm pillows propping up the knees when lying on the back
- To stay active, resume normal activities and to return to work as soon as possible
- Prolonged bed rest not recommended
- Normal movements may produce some pain which should not be harmful if activities are resumed gradually and as tolerated, no need to be pain-free before returning to normal activities or work
- Work adjustments can make an early return to work possible, this may be arranged by an Occupational Health department if available
- Keeping as active as possible and exercising regularly is important to reduce the risk of recurrence
- To read information at www.backcare.org.uk
- To seek medical advice if any red flag symptoms or signs (especially if worsening pain, bilateral leg pain, weakness in legs or feet, perianal, perineal or genital sensory loss, urinary retention or incontinence, faecal incontinence) and to contact own GP if no improvement or ongoing symptoms after 3-4 weeks
Reference(s):
NICE CKS: Back pain - low (without radiculopathy)