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Lower Back Pain

TODO: Complete NICE CKS - up to 'diagnosis' stage

Differential​

  • Serious Underlying Causeses include
    • Cauda equina syndrome.
    • Cancer of the spine.
    • Spinal fracture due to trauma or osteoporotic collapse.
    • Spinal infection.
  • Non-specific low back pain should be diagnosed in people with low back pain which varies with posture and is exacerbated by movement; may be related to trauma, or musculoligamentous strain.
  • Specific Causes include: sciatica, vertebral fracture, intra-abdominal pathologies, and more rarely, ankylosing spondylitis, cancer, and infection.

Risk Factors​

  • Obesity.
  • Physical inactivity.
  • Occupational factors (such as heavy lifting).
  • Depression and other psychological conditions.

History and Examination​

Red Flag Features​

  • Cauda equina syndrome. Red flags include:
    • 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).
    • Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
    • Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
    • Unexpected laxity of the anal sphincter.
  • Spinal fracture. Red flags include:
    • Sudden onset of severe central spinal pain which is relieved by lying down.
    • A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting 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 may be point tenderness over a vertebral body. 
  • Cancer. Red flags include:
    • The person being 50 years of age or more.
    • 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 (for example, at stool, or when 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.
    • Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
  • Infection (such as discitis, vertebral osteomyelitis, or spinal epidural abscess). Red flags include:
    • Fever
    • Tuberculosis, or recent urinary tract infection.
    • Diabetes.
    • History of intravenous drug use.
    • HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.

Investigation​

  • X-rays of the back should not routinely be requested to diagnose non-specific low back pain.

Management​

  • Refer urgently to a neurosurgeon or orthopaedic surgeon if there are red flags including progressive, persistent, or severe neurological deficit.
  • Paracetamol +/- NSAID or Codeine
    • Ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less). Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms
    • Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or for people over 45 years with low back pain in accordance with NICE guidance.
  • Benzodiazepine for muscle spasm (Diazepam)
  • In those with high risk for back-pain related disability, or those where pain is not improving or worsening: group exercise, CBT, physiotherapy, and/or consider referral to specialist low back pain services for assessment.

Prognosis​

  • Most episodes of non-specific back pain resolve within four weeks with self-care.
  • People who have had low back pain often have episodes of recurrence and may develop repeated 'acute on chronic' symptoms.

High-Risk for Chronic Pain and Disability​

  • People with low back pain who are at higher risk of long-term pain and functional disability include those with:
    • Pain lasting for longer than 12 weeks.
    • Psychosocial distress.
    • Maladaptive coping strategies such as avoidance of work, movement, or other activities due to fear of exacerbating back pain.
    • Pain coping characterised by excessively negative thoughts about the future ('catastrophizing').

Patient Education​

  • Providing information about the expected time course of pain, self-help measures, advice about staying active, resuming normal activities, and returning to work as soon as possible.

Reference​

https://cks.nice.org.uk/topics/back-pain-low-without-radiculopathy/