“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

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