Musculoskeletal System >
Back Pain
“Acute/chronic tenderness due to mechanical or non-mechanical causes that can be localised to the cervical, thoracic, lumbar, sacral and coccygeal spine or felt in paravertebral areas. The pain can radiate to other areas“
Risk Factors
- Modifiable:
- Decreased fitness level
- Weight gain
- Smoking
- Job-related factors – heavy lifting/pushing/pulling or long periods of sitting with poor posture
- Non-Modifiable:
- Age
- Genetic predisposition
- Psychological factors e.g. depression and stress
Aetiology & Pathophysiology
- Mechanical:
- Muscle and ligament strain (excessive stretching that can lead to tearing)
- Disc herniation (a displaced spinal disc that compresses spine/nerve root)
- Spinal stenosis (narrowed spinal canal and intervertebral foramina cause joint stress and can compress spine/nerve roots)
- Spinal osteoarthritis (degeneration of cartilage in facet joints and production of spurs that put pressure on nerves)
- Osteoporosis → vertebral fractures (decreased bone mass increases vertebral fragility and susceptibility to fractures)
- Non-mechanical:
- Multiple myeloma and bone metastases in vertebrae (weakened bone + tumour compression of spinal cord/nerves)
- Seronegative spondylarthritis (a group of chronic inflammatory arthritic diseases affecting axial skeleton where the rheumatoid factor is absent)
- Vertebral osteomyelitis (infection of vertebral bone and bone marrow due to direct or haematogenous spread
Clinical Presentation
- Strain – typically paravertebral tenderness on palpation that is exacerbated by movement and varies with posture and time.
- Disc herniation – acute onset severe stabbing/electric shock-like pain and radiation to dermatome of impinged nerve e.g. L4-L5 and S1-S3 can lead to sciatica
- Spinal stenosis – neurogenic claudication = pain exacerbated by walking or standing upright and relieved by sitting or bending forward
- Spinal osteoarthritis – chronic neck and lower back pain with morning stiffness
- Osteoporosis vertebral fracture – sudden severe back pain that worsens on standing/walking and is relieved by lying down, structural spine deformity and point of tenderness
- Myeloma and metastases – gradual progressively worsening back pain that is worst at night + weight loss
- Seronegative spondylarthritis – slowly progressive lower back pain. Worse at night, morning stiffness that improves with exercise.
- Vertebral osteomyelitis – back pain, fever, night
Investigations
- Back physical examination
- Imaging – only considered in specialist care/likely to change management
- MRI/X-Ray/CT of the spine, DEXA scan, blood tests
Management
- For back pain with/without sciatica:
- Pharmacological:
- NSAIDS
- Skeletal muscle relaxants
- Weak opioids
- Non-pharmacological:
- Exercise programs
- Physical therapy
- Manual therapy
- Psychological therapy
- Pharmacological:
Complications
- Chronic pain and discomfort
- Nerve damage (due to pinched nerves) and potentially paralysis
- Physical disability
- Depression and insommia