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Low Back Pain Cheat Sheet (DRAFT) by

LBP Triage, classifications , S&S

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Low back pain (LBP)

- Pain between lowest ribs and inferior gluteal folds
Triage: Non-sp­ecfic, + neurol­ogical involv­ement, + serious pathology (red flags)
Risk factors of chronic back pain: NRS >7 at presen­tation, Long duration of symptoms, Poor locus of control, Sciatica, Numerous episodes, Job dissat­isf­action, Depression or anxiety, Activity intole­rances, Poor endurance of lumbar extensors, Poor physical fitness

Non-sp­ecfic LBP

- 20 yrs -55 yo
- Lumbro­sacral region, buttocks and thighs
- Pain is mechan­ical, better with rest, worst with activity, sudden motion can cause reflex spasm of paraspinal muscles
- Patient appears to be well
- Deep, dull ache, stiffness - worse at end of the day
- unilateral leg pain that does not extend past the knee
- ESR, CRP, Calcium phosphate + Alkaline phosphate WNL

Red Flags

- <20yo onset or >55yo
- Violent Trauma
- Constant, progre­ssive, non-me­cha­nical pain
- Previous hx of cancer, use of cortic­ost­eroids, drug abuse or HIV
- System­ically unwell, weight loss
- Persis­tant, severe restri­ction on lumbar flexion
- Widespread neuro signs/­sym­ptoms
- Structural deformity
- ESR >25
- Plain X-ray showing VB collap­se/bone destru­ction
Cauda Equina: Difficulty with mictru­rition , loss of anal sphincter tone/f­aecal incont­inence
- Saddle anaest­hesia @ anus, perine­um/­gen­itals
- Widespread (>1 NR)
- Progre­ssive motor weakness in the legs
- Gait distur­bances
Inflam­matory: <40 yo, Marked morning stiffness, persisting limitation of spinal movements in all direct­ions, Iritis, Skin rashes, Colitis and urethral discharge, Family Hx
Referral from abdominal organs: GI, Urinary, Gynaec­ologic symptoms
- Getting out of bed to pace around at night
- Pain + Fever consider: Epidural abscess, Septic diskitis, osteom­yel­itis, bacter­emi­a/i­nfe­ction endoca­rditis
- Pain + Weight loss/a­norexia = malign­ancy, mets
- Pain + bowel/­bladder dysfun­ction - spinal cord disease (corti­cos­teriods = compre­ssion f#, antico­agu­lants = retrop­eri­toneal haemor­rhage)

Yellow Flags

- Unsati­sfa­ctory restor­ation of activities
- Failure to return to work
- Unsati­sfa­ctory response to treatment
- Depression
- Passive coping strategies
- Higher disability levels
Use the Bourne­mouth Questi­onnaire (BQ) for psycho­social elements of LBP

Serious Disorders

- Osteom­yelitis
- Malignancy
- TB
- Cauda Equina

Pitfalls

- Spondy­loa­rth­rop­athies - Psoriatic Arthritis, AS, Reiters, IBD - UC/Crohns
- Vascular causes
- Manipu­lable lesions + OA can develop together

Referals

Urgent: Cauda Equina, Spinal F#, Dissecting AAA
Other: Neopla­sm/­inf­ection, Back pain without a clear diagnosis, Paget's , other causes of non-me­cha­nical LBP

Hx

Facet : Sudden onset, localised spasm, protective lateral deviation, relieved by sitting and bending forward, hyperl­ordosis present, aggravated by movement + transf­erring from sitting to standing, pain on extension
Systemic: Not associated with body position, Pain worse at rest, Night pain
Spondy: Pain aggravated by standi­ng/­wal­king, relieved by sitting
Disc: Aggravated by sitting, improved with standing
pain related to posture, movement and posture - especially forward flexion
relieved by lying down

Invest­iga­tions

- X-rays
- MRI
- CT
- Bone Scan
- DEXA Scan
- Urinalysis
- ESR/CR­P/FBC
- Anti-CCP
- SAP
- PSA (males >50 yo)
- Elderly
- Consti­tut­ional symptoms
- Failed Conser­vative therapy

in children

Consider: mechanical disorders of interv­ert­ebral joints - psycho­logical (look for problems at home, school and/or sport), Spondy­lol­ist­hesis
- Rule out: Osteoid Osteoma & Malignant osteos­arcoma

In Elderly

Consider: Malignancy
- Degene­rative spondy
- VB pathol­ogical F#
- Occlusive Vascular Disease
- Mechanical LBP - localising discomfort to LS area - worse with stretc­hing, twisting walking or bending
Aching in Buttoc­k/t­high, relieved by rest can present at night when turning around­/ch­anging positions during sleep

Sciatica

- Sharp/­tin­gli­ng/­sho­oti­ng/­ele­ctrical pain
- aggravated by coughing, straining, sneezing
- SMR in the affected dermatone

Spondy­lol­ysis/AS

See Sheet

Abnormal Illness Behaviour (AIB)

- Vague and poorly localised pain
- A yellow flag
- Linked with anxiety, depression and hx of substance abuse
- Waddell:
1. Pain at the tip of the tailbone with direct injury {{nl)) 2. Whole leg pain in a stocking distri­bution
3. Whole leg numbness in a stocking distri­bution that occurs at times
4. Whole leg giving way when other times it works fine
5. Complete absence of any periods with very little pain in the past year - reports pain is getting worse on each consul­tation
6. Intole­rance of, or reactions to many different treatments
7. Emergency admission to hospital with simple backache not due to fracture
- Behavi­oural signs:
1.Wide­spread tender­ness, crossing anatomical borders
2. Waddells both tests reproduce pain
3. SLR normal when patient is distracted
4. More widespread weakness - weakness is jerky
- When you cannot use these classi­fic­ations : Patients with possible serious pathol­ogy­/wi­des­pread neurol­ogical pathology, >60 yo, Ethnic minorities

Management

- Usually resolves in 6-12 weeks
ACute LBP: Advice to stay active + NSAIDs, SMT, Behaviour therapy, multid­isc­ipl­inary treatment (subacute)
Chronic LBP: Exercise therapy (stren­gthen core muscles), intensive multid­isp­linary treatment progra­mmes, muscle relaxants, analge­sics, acupun­cture, antide­pre­ssants, back schools, CBT, NSAIDs, SMT
- Heat, cold packs and massage = acute phase (2-4 weeks)
Only refer for surgery when:
- Progre­ssive neurologic deficit is present
-Intra­ctable pain, not getting better with conser­vative care
- Structural lesions present