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

Complications

• Chronic pain and discomfort
• Nerve damage (due to pinched nerves) and potentially paralysis
• Physical disability
• Depression and insommia