A forty-year old gentleman, walks into your clinic complaining of low back pain, which has been present for the past four days. The pain is quite severe and poorly localized, forcing the patient to abstain from work. The patient is not on any medication and has no relevant past medical history, except for an episode of back pain years back. He is annoyed by the pain and by the fact that he had to stop working. What would you do?peer-reviewe

Abela, Jurgen C.

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44 Malta Medical Journal    Volume 16   Issue 01   March 2004A Case of Acute Low Back PainIn PracticeJürgen C AbelaJürgen C Abela  MD, MRCGPDepartment of Primary Care, Harper Lane, Floriana, MaltaEmail: jurgenabela@waldonet.net.mtA forty-year old gentleman, walks into your cliniccomplaining of low back pain, which has been present for thepast four days. The pain is quite severe and poorly localized,forcing the patient to abstain from work.  The patient is not onany medication and has no relevant past medical history, exceptfor an episode of back pain years back. He is annoyed by thepain and by the fact that he had to stop working.What would you do?IntroductionAcute low back pain is an extremely common complaint,with a one-month prevalence of 35-37% and a slightly higherprevalence in females1. It poses a challenge to the clinical andcommunicating skills of the clinician. The important pointswhich this consultation raises are:• The need to exclude uncommon serious causes of acute lowback pain.• The need to identify risk factors that may lead to chroniclow back pain and related co-morbidities.• Addressing patient concerns and treatment of symptoms.• Using investigations when truly needed and not as an escaperoute.Many structures in the back may give rise to pain (Table 1),occasionally with similar distribution.  Satisfactory treatmentof low back pain depends on an accurate diagnosis. However,identifying the actual structure causing the pain is often notpossible because of the difficulty in localising the source of pain.This needs to be understood by both the patient and the doctor.AssessmentThe initial assessment should start by exploring the ideas,concerns and expectations of this gentleman2.  Many patientsare particularly troubled by the pain and movement restriction,but some are more troubled by the possibility of serious disease.Back pain triage3 is the medical model of diagnosis to excludeserious pathology and at the same time identify clinicalsyndromes. History and examination are used to identifydiseases of an inflammatory, neoplastic, infective or metabolicnature, in addition to specific causes of mechanical pain,symptomatic disc prolapse, stenosis and instability.  The so-called Red flag symptoms and signs are indicators of seriousdisease (Table 2).  A thorough examination will also serve tofurther allay the patient’s fears. Unfortunately studies show thatup to 27% of GP’s do not examine for limb reflexes when dealingwith back pain, and the majority do not check for muscleweakness or sensation4.In the case of systemic back pain, examination shouldinclude the testicles and prostate in males and breasts infemales, since neoplasms of these organs metastasisepreferentially to the skeleton.Table 1: The more common causes of Back PainMusculoskeletal ConditionsLigamentous StrainMuscle/soft tissue injurySubluxed facet jointSacroiliac strainProlapsedintervertebral discFractureScoliosisDegenerative Conditions OsteoarthritisSpondylosisNeoplastic conditions Primaryor secondary growthReferred pain GynaecologicalRenalOther abdominal organsInfection Herpes zosterOsteomyelitisPsychological DepressionMalingeringMetabolic OsteoporosisPaget’s DiseaseRheumatic conditions Rheumatoid arthritisAnkylosing spondylitisFrom Tutorials in General Practice by Mead and Patterson,1999,3rd ed. Churchill Livingstone.Malta Medical Journal    Volume 16   Issue 01   March 2004 45Identification of risk factors (such as dissatisfaction withemployment and low levels of physical activity) on the part ofthe patient associated with a less favourable outcome is anotherimportant aspect of assessment.Yellow flags (Table 2) are beliefs or behaviours on the partof the patient that may predict a poor outcome.  Useful interviewprompts to identify yellow flags are listed in Table 3.An issue particularly relevant to certain populations is theneed of investigations, mainly radiography, to put the patient’smind at rest, hopefully help in the recovery process andoccasionally serve as an escape route for the clinician. Indeed,radiography for first presentation of back pain is not associatedwith a better clinical outcome5 and the minor possibility ofimproved patient satisfaction should be balanced against thehigh radiation dose involved6. Also, it is a known fact that thereis little correlation between radiologically detectabledegenerative changes and symptoms7, and that there is lowyield8. Thus radiography should ideally be considered eitherwhen serious disease is suspected, or when the patient fails toimprove.Blood tests such as Erythrocyte Sedimentation Rate (ESR),C-reactive protein, a blood count and a biochemical screen (uricacid, alkaline phosphatase, calcium and phosphate levels) maybe ordered if an inflammatory or neoplastic process is suspected.Undue distress, depressive and anxiety disorders mayaccompany or even complicate back pain, and need to be keptin mind when assessing patients.ManagementBesides the purely medical issues mentioned, a patientpresents as a person, with many concerns and related problemswhich also need to be addressed in this consultation, and hereis where a GP, more than any other specialist, has a crucial role.It is important to establish an agreed management plan withthe patient.  Analgesia should be high on the doctor’s agenda asindeed the first concern of the patient is pain relief.  Non-steroidal anti-inflammatory drugs (NSAIDs)9 or paracetamoleffectively decrease low back pain.  Recently, COX-2 inhibitorshave been introduced, and these are the drugs of choice giventhe equivalence to NSAIDs regarding analgesia and bettergastrointestinal side-effect profile10.Alternatively, weak opioid-paracetamol mixtures may beused when the above fail. Strong opioids should be avoided.Using analgesics regularly and not on as required basis shouldbe encouraged as the former is a more effective managementstrategy.Muscle relaxants are infrequently used in the treatment ofback pain.  However they do effectively reduce low back pain11 .There are various types of muscle relaxants, the most commonlyused being diazepam, baclofen and thiocolchicoside.In the eventuality that the patient suffers from simple backpain, he should be encouraged to continue with ordinary activityand avoid bed-rest 12.The evidence for the effectiveness of further treatment, suchas manipulation, acupuncture, lumbar supports and backexercises is conflicting and not consistent.People who suffer from back pain have an associatedincreased incidence of psychological distress factors 13. The riskof chronicity, in the case of non-specific back pain is reduced by• Paying attention to the psychological aspects of symptompresentation with particular emphasis on identification ofyellow flags• Avoiding unnecessary, excessive or inappropriateinvestigations, as these may further enhance fear of seriousdisease• Avoiding inconsistent care as this may cause the patient tobe overcautious• Giving advice about how to prevent recurrence (goodposture, sensible lifting and not lifting excessive loads)Table 2: Red and Yellow Flags in back pain “Triage”Red Flags Yellow FlagsPresentation < 20 yearsor onset >55 years Belief that back painis harmful or potentiallyseverely disablingNon-mechanical Pain Fear-avoidance behaviourand reduced activity levelsThoracic Pain Tendency to low mood andwithdrawal from socialinteractionPast History Expectation of passive• Ca, treatment(s) rather than• Steroids belief that active• HIV participation will helpUnwell and weight lossWidespread neurological disturbanceStructural deformityCauda Equina Syndrome• Sphincter disturbance• Gait disturbance• Saddle anaesthesiaAdapted from Guidelines for the Management of Acute Back Pain,RCGP 1996.Table 3: Useful interview prompts to elicit “Yellow Flags”• What do you understand is the cause of your back pain?• What do you think will help you?• How are the others responding to your back pain(employer and family)?• What have you done so far to cope with your back pain?• Have you had time off in the past due to back pain?• When do you think you will be able to return to work?46 Malta Medical Journal    Volume 16   Issue 01   March 2004Future return to work is another important topic whichneeds to be tackled. Any depressive or anxiety disorder shouldbe treated accordingly.    Giving positive messages in the case ofsimple back pain will help.Given the many issues involved in this particular scenario,Pendleton’s Consultation Model14 is an important and usefultool to use.  It is made up of seven steps, which are summarizedbelow:1. Defining reason for patient attendance – including ideas,concerns expectations and effects of the problem2. Consider other problems – including risk factors which maybe also present3. Action – Choosing with the patient an appropriate actionfor each problem4. Understanding – Achieving a shared understanding withthe patient5. Active Management  – Involving the patient in themanagement plan, encouraging him to take appropriateresponsibility6. Resources – using time effectively7. Relationship – Establishing a relationship with the patientwhich helps to deal with possible complications and achieveother tasks.The last five steps are particularly suitable, since they allowpatient participation and the possibility of follow-up in casesymptoms do not resolve. The clinician is also given a furtheropportunity to discuss the situation with the patient, reviewdiagnosis and, if need be, order investigations.It is best to review the patient after a week or ten days haveelapsed.Referral should be considered if:1. Red flags are present at the time of assessment. Urgencydepends on the particular situation of the patient.2. Cauda equina syndrome is diagnosed.  This needs to beassessed and treated.3. There is failure to improve, particularly in the case of nerveroot pain.PrognosisThe majority of cases of acute low back pain are due to“simple”, “non-specific” back pain. 58% improve rapidly in thefirst month, while further improvement is experienced for upto three months. 73% may have a recurrence within 12 months15.In the case of sciatica, the natural history of disc prolapse isusually one of spontaneous recovery with time.References1 Papageorgiou AC, Croft PR, Ferry S, Jayson MIV, Silman AJ.Estimating the prevalence of back in the general population.Evidence from the South Manchester Back Pain Survey. Spine1995; 20:1889-94.2 Tate, P.2001. The Doctor’s Communication Handbook. 3rd.edition. Radcliffe Medical Press.3 Royal College of General Practitioners. (1996). Clinical Guidelinesfor the Management of Acute Low Back Pain. Available fromhttp://www.rcgp.org.uk/clinspec/guidelines/backpain/backpain19.asp (Accessed 23rd December 2003)4 Little P, Smith L, Cantrell T, Chapman J, Langridge J, PickeringR. General Practitioners’ management of acute back pain: a surveyof reported practice compared with clinical guidelines. BMJ 1996;312:485-488.5 Kerry S, Hilton S, Dundas D, Rink E, Oakeshott P. Radiographyfor low back pain: a randomised controlled trial and observationalstudy in primary care. BJGP 2002; 52: 469-474.6 Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, PringleM. Radiography of the lumbar spine in primary care patients withlow back pain: randomised controlled trial. BMJ 2001; 322:400-4057 Magora A, Scwartz A. Relation between low back pain syndromeand X-Ray findings. 1. Degenerative osteoarthritis. Scand JRehabil Med 1976; 8:115-25.8 Jenner JR, Barry M. ABC of Rheumatology: Low Back Pain. BMJ1995; 310:929-932.9 Tulder MW, Scholten RJPM, Koes BW, Deyo RA. Non-steroidalanti-inflammatory drugs for low back pain (Cochrane Review).Available from http://www.cochrane.org/cochrane/revabstr/AB000396.htm (Accessed on 20th December 2003).10 Bombardier C, Laine L, Reicin A et al. for the VIGOR StudyGroup.  Comparison of Upper Gastrointestinal toxicity ofRofecoxib and Naproxen in Patients with Rheumatoid Arthritis. NEng J Med 2000, 343: 1520-1528.11 Tulder MW van, Tuoray T, Furlan AD, Solway S, Bouter LM.Muscle relaxants for non-specific low back pain (CochraneReview). Available from http://www.cochrane.org.cochrane/revabstr/AB004252.htm (Accessed on 20th December 2003).12 Malmivaara A, Hakkinen U, Aro T. et al. The treatment of acutelow back pain – bed rest, exercises, or ordinary activity. N Engl JMed 1995; 332:351-355.13 Main CJ, de C Williams A. ABC of Psychological Medicine:Musculoskeletal Pain. BMJ 2002; 325:534-537.14 Pendleton, Schofield, Havelock, Tate. 1984. The consultation – Anapproach to Teaching and Learning. Oxford University Press.15 Pengel LHM, Herbert R, Maher CG, Refshauge KM. Acute LowBack Pain: systematic review of its prognosis. BMJ 2003;327:323-331.

A case of acute low back pain

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A case of acute low back pain

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