The back

Early management of persistent non-specific low back pain: summary of NICE guidance 2009

Pain diagram for patients

Summary

History

The red flags define the extent of examination

Age under 20 or over 55
Non-mechanical pain (capsular pattern)
(Thoracic pain)
Ca, steroids HIV or other significant past history
Unwell, wt loss
Widespread neurology eg bilateral leg signs
Structural deformity
Persistent night pain
Saddle anaesthesia/sphincter disturbance

Can use time as a tool. If no sensory symptoms, not worthwhile looking for sensory signs. remember though that examination may be a therapeutic procedure.

Examination

Inspection
Palpation
Percussion

Landmarks

C7/T1	Prominent
T7/T8	Lower border of scapula
L4 body	Iliac crests
S2	Dimples at PSIS
Tip coccyx	Ischeal tuberosities

Patterns of stiffness

Capsular pattern: stiffness in all directions (acute pain, arthritis, inflammatory, destructive).
Non-capsular pattern: stiffness in one direction (mechanical). Dysfunction = stress x vulnerability

	Reversible	Not reversible
Pathological	?	X
Structural	?	X
Functional	?	X

Biomedical:

review diagnostic triage
- nerve root problem
  serious spinal pathology
ESR and plain X-ray

Psychological:

attitudes and beliefs about back pain
- fear avoidance beliefs about activity and work
- personal responsibility for pain and rehabilitation
psychological distress and depressive symptoms
illness behaviour

Social:

family
- attitudes and beliefs about the problem
- reinforcement of disability behaviour
work
- physical demands of job
- job satisfaction
- other health problems causing time off or job loss
- non-health problems causing time off or job loss

Waddell tests for functional backpain

Tenderness to touch
Simulated axial loading
Distraction tests
Non-anatomical regional disturbance
Over-reaction

Diagnostic Triage including 'Red Flags'

Simple backache

Presentation between ages 20-55
Lumbosacral region, buttocks and thighs
Pain "mechanical" in nature
- varies with physical activity
- varies with time
Patient well
Prognosis good

Nerve root pain

Unilateral leg pain worse than low back pain
Pain generally radiates to foot or toes
Numbness and paraesthesia in the same distribution
Nerve irritation signs
- reduced SLR which reproduces leg pain
Motor, sensory or reflex change
- limited to one nerve root
Prognosis reasonable
- 50% recover from acute attack within six weeks

RED FLAGS for Possible Serious Spinal Pathology

Presentation less than age 20 or onset over age 55 years
Violent Trauma: eg fall from a height, RTA
Constant, progressive, non-mechanical pain
Thoracic pain
PMH - Carcinoma
Systemic steroids
Drug abuse, HIV
Systemically unwell
Weight loss
Persisting severe restriction of lumbar flexion
Cauda equina syndrome/widespread neurological disorder
- Difficulty with micturition
- Loss of anal sphincter tone or faecal incontinence
- Saddle anaesthesia about the anus, perineum or genitals
- Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance
- Sensory level
Inflammatory disorders (ankylosing spondylitis and related disorders)
- Gradual onset before age 40
- Marked morning stiffness
- Persisting limitation spinal movements in all directions
- Peripheral joint involvement
- Iritis, skin rashes (psoriasis), colitis, urethral discharge
- Family history

Risk factors for chronicity

Previous history of low back pain
Total work loss (due to low back pain) in past twelve months
Radiating leg pain
Reduced straight leg raising
Signs of nerve root involvement
Reduced trunk muscle strength and endurance
Poor physical fitness
Self-rated health poor
Heavy smoking
Psychological distress and depressive symptoms
Disproportionate illness behaviour
Low job satisfaction
Personal problems - alcohol, marital, financial
Adversarial medico-legal proceedings
Diagnostic Triage including 'Red Flags'

Simple backache
- Presentation between ages 20-55
- Lumbosacral region, buttocks and thighs
- Pain "mechanical" in nature
  - varies with physical activity
  - varies with time
- Patient well
- Prognosis good
Nerve root pain
- Unilateral leg pain worse than low back pain
- Pain generally radiates to foot or toes
- Numbness and paraesthesia in the same distribution
- Nerve irritation signs
  - reduced SLR which reproduces leg pain
- Motor, sensory or reflex change
  - limited to one nerve root
- Prognosis reasonable
  - 50% recover from acute attack within six weeks
RED FLAGS for Possible Serious Spinal Pathology
- Presentation less than age 20 or onset over age 55 years
- Violent Trauma: eg fall from a height, RTA
- Constant, progressive, non-mechanical pain
- Thoracic pain
- PMH - Carcinoma
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Weight loss
- Persisting severe restriction of lumbar flexion
- Cauda equina syndrome/widespread neurological disorder
  - Difficulty with micturition
  - Loss of anal sphincter tone or faecal incontinence
  - Saddle anaesthesia about the anus, perineum or genitals
  - Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance
  - Sensory level
- Inflammatory disorders (ankylosing spondylitis and related disorders)
  - Gradual onset before age 40
  - Marked morning stiffness
  - Persisting limitation spinal movements in all directions
  - Peripheral joint involvement
  - Iritis, skin rashes (psoriasis), colitis, urethral discharge
  - Family history
Risk factors for chronicity
- Previous history of low back pain
- Total work loss (due to low back pain) in past twelve months
- Radiating leg pain
- Reduced straight leg raising
- Signs of nerve root involvement
- Reduced trunk muscle strength and endurance
- Poor physical fitness
- Self-rated health poor
- Heavy smoking
- Psychological distress and depressive symptoms
- Disproportionate illness behaviour
- Low job satisfaction
- Personal problems - alcohol, marital, financial
- Adversarial medico-legal proceedings

The whole examination

Standing:

Inspection
- Active movements
  - Flexion:
    - "head forwards, shoulder forwards, roll forwards". Functional scoliosis resolves, a structural scoliosis does not.
    - Schrobers test: 5cm below to 10cm above L4 - normal more than 5cm.
  - Extension
    - L&R side flexion: finger tip to floor (spondyloarthropathy). Pain on same side likely to be facet joint, pain on opposite side likely to be ligament.
    - Passive movements: range, quality of movement, end of range change, compression etc.
Palpation
Root signs
Active plantar flexion

Supine:

SLR +/- Lasegues sign: can be nerve root or spasm
SI joints
Hip joints
Reflexes: plantar response is an upper motor neurone reflex
Sensation
Palpation: SI joints, pelvic squeeze, stress test (hyperextend hip down over edge of couch)

Root signs:

SLR
Resisted hip flexion
Resisted foot dorsiflection
Resisted toe extension
Resisted foot eversion

Prone:

Root signs:

Femoral stretch test
Resisted knee extension
Resisted knee flexion
Resisted buttock contraction

Inappropriate signs

This is "pain behaviour"

Axial loading
Distraction (eg SLR vs sitting)
Sensory symptoms

Notes

"Think inflammatory" - is this likely to be spondylitis?
Disc lesions with scoliosis do best with surgery.
Schuermanns osteochondritis: not sinister, teenagers.

NICE referral guidelines

Early management of persistent non-specific low back pain: summary of NICE guidance 2009