3558.pdf
Media
- extracted text
-
The Painful Back
PRACTICAL ASPECTS OF MANAGEMENT
iQi Produced by Medical Education Services Limited
The Painful Back
PRACTICAL ASPECTS OF MANAGEMENT
Published by The MEDICINE Publishing Foundation and produced by Medical
Education Services Limited on behalf ofThe MEDICINE Group. Pembroke House,
36 '3'7 Pembroke Street. Oxford, Great Britain 0X1 1BL
Sponsored by Reckitt & Colman Pharmaceutical Division
ISBN 0 906S1- 56 0
Design, composition and artwork by Comersgate .Art Studios.
Oxford, England
Printed by Cradley Print pic, Warley. West Midlands
First published July 1983. Reprinted April 1984. Second reprint December 1984.
© 1983 Medical Education Services Limited
4-2U
Tbtsfpiiblicatton is copyright under the Berne Cont ention and the Universal Copyright
Contention. All rights reserved No part of this publication may he reproduced or
transmitted in any form by any means including photocopying microfilming and
recording without the written permission of the copyright holder, application for which
should be addressed to the publisher. Such written permission must always he obtained
before any part of this publication is stored in a retrieval system of any nature.
Citation
The Painful Back. Practical aspects of management.
Oxford: MEDICINE Publishing Foundation. 1983.
British Library Cataloguing in Publication Data
The Painful Back.
1. Backache
616./'306
RD768
0'5 SSZ'
370
ISBN 0-906817-56 0
This booklet was compiled bv Stephane Aucbincloss URCP. .Medical Editor.
TheMEDICINE Group
Contents
1 Introduction
4
2 Symptoms
5
3 Examination
8
4 Investigation
15
5 The malingerer
16
6 Conservative management is
7 Referral
20
8 Surgery
21
9 Prevention
22
10 Conclusion
23
PAINFUL BACK
introduction
The aim of this booklet is to assist the general practitioner in the
diagnosis and management of back pain. In a busy surgery it is often difficult to
assess a patient with a painful back accurately and to select the appropriate
course of treatment. Important options are:
o to investigate with radiography and blood tests
o to refer immediately to an orthopaedic surgeon, physician or
rheumatologist
O to manage the patient conservatively.
Acute back pain may be a considerable drain on community resources.
The young mother who is suddenly unable to cope with her family, the
labourer who is off work for months, and the old age pensioner with
immobility due to severe back pain are well recognized problems.
Furthermore, the cost of back pain to industry and society is consider
able. Each year, back pain causes a period of incapacity in more than 375,000
people in the UK, accounting for the loss of 26 million working days. It is the
commonest cause of early retirement from industry and costs approximately
£1000 million in medical care, sickness benefit and lost production each year.
The size of the problem is therefore enormous, with 50,000 people at home
with back pain on any working day, and 4 out of 5 people having back pain at
some time in their lives. Back pain accounts for a third of all the diseases of the
musculoskeletal system, and I in 40 of ail consultations in general practice is
accounted for by backache.
One of the most important points in diagnosis and management of
back pain is to identify those patients who have a severe underlying cause for
their pain. Such patients are diagnosed and dealt with appropriately; the other
patients can be managed conservatively by the general practitioner. Minor
trauma or strain, so called 'lumbago', is the most common cause of back pain
and this responds well to conservative management.
Most patients with acute back pain respond rapidly to treatment; 40%
are better in a week and 56% are better within a month. If recovery is delayed.
the initial diagnosis should be reassessed. Only I patient in 20 with back
problems is referred to a hospital and of these a proportion are better before
the hospital appointment is kept. Thus, most cases of back pain can be dealt
with adequately by the general practitioner at his surgery; his role cannot be
overestimated.
4
PAINFUL BACK
Symptoms
2.1 Which points in the history are useful in
diagnosis?
When taking the history it is important to discover whether the attack
is the first the patient has experienced and whether the pain was felt suddenly
or developed slowly. At the beginning of an attack, muscle spasm may
suddenly prevent movement. Sometimes the pain is present on awakening.
while in other instances it may increase gradually during the day. The general
practitioner should determine whether the pain is intermittent or constant.
decreasing or increasing in severity, and whether there are aggravating or
relieving factors.
The precipitating cause of the symptoms is important (Figure I). A
history of a jarring strain, a fall or unaccustomed lifting of a heavy object may
I Important causes of back pain
T rauma
Sacro-iliac strain
• Crush fractures due to:
severe trauma (fall from height)
osteoporosis
osteomalacia
malignancy
• Fracture of transverse processes
• Subluxated facet joints
• Minor trauma resulting in strains
Inflammatory arthritis
• Sacro-lllitis due to:
ankylosing spondylitis
rheumatoid arthritis
inflammatory bowel disease
Reiter's disease
psoriasis
Malignancy
Lumbosacral strain
® Primary tumour of bone or cartilage
• Secondary tumours in bpne (arising from
tumours of breast, prostate, lung, kidney.
thyroid, pancreas and ovary)
• Multiple myeloma
• Spondylosis
• Osteoarthritis
Degenerative disorders
Metabolic disorders
• Paget's disease
• Osteomalacia
Infection
• Osteomyelitis
• Tuberculosis
• Pyogenic disc space infections
Congenital disorders
• Spinal stenosis
‘Malingerer’
Prolapsed intervertebral disc
• Psychogenic causes
5
THE PAINFUL BACK
be pertinent. Acute back pain in young adults and middle-aged patients is often
caused by apparently minor trauma, such as a jarring movement in a car or a
bus. or a twisting and bending movement when lifting even a small weight.
The precise distribution of the pain and its possible radiation into new
areas are also important factors to consider when taking the history (Figure 2).
Pain due to strain tends to remain in the back. Root compression, however,
results in pain following the nerve root distribution. In sciatica, the pain
radiates below the knee and, after a week, may be more intense in the leg than
in the back.
Occasionally, certain movements such as bending or twisting may be
associated with pain; in nerve root compression the pain is increased by
coughing and sneezing. Facet joint problems cause locking of the back on
rotation, while pain relief on sitting forward might suggest spinal stenosis.
The first attack of back pain in a patient over 50 years of age is
generally due to either disc prolapse or strain, but mechanical problems usually
occur before this age. A serious underlying cause should be suspected in the
older patient if the pain is severe, unremitting and is not relieved by rest or
analgesia.
2 Symptoms and history
• Age
• Sex
o Precipitating cause
O Associated features, such as fever, malaise or headache
® Cause of pain (minimal trauma, severe trauma)
o Location of pain
• Severity of pain and how it interferes with daily activities
O Presence of paraesthesia or other neurological symptoms
• Any radiation of pain
• Relationship of pain to posture, time of day. and exercise or movement
® Exacerbating or relieving factors (e.g. coughing or sneezing)
• Drug therapy
• Previous musculoskeletal problems or back pain
• Amount of exercise (e.g. participation in sports)
© Occupational history
• Psychological status
2.2 What is the commonest presentation of
back pain in a child?
The commonest cause of back pain in a child may be ligamentous strain
either of the lumbar spine or neck, caused by unusual or excessive athletic
activity. Acute'torticollis is often seen in general practice and is commonly
associated with an upper respiratory tract infection or viraemia. It can often be
treated with mild analgesics, reassurance and. sometimes, an ether local
6
THE PAINFUL BACK
anaesthetic spray. A patient under the age of 18 years whose back pain does
not respond rapidly to rest should be referred to a specialist. In a few of these
patients the cause is organic in nature, and these few must be identified.
2.3 Which type of patient presents with a
prolapsed intervertebral disc?
The patient with a prolapsed intervertebral disc is usually aged
between 25 and 50 years. He most commonly presents a few days after jarring
and straining his back, but sometimes there is no precipitating event. Gener
ally, the onset of pain is quite sudden: the patient is seized with agonizing pain
in the lumbar area while twisting, bending or stooping. Initially, he is unable to
move but during the next few days the acute pain gradually becomes less
severe. Two to three days after the acute phase, the pain radiates from one or
other buttock down the back or side of the thigh into the calf or foot. Tingling
or numbness may be present in the calf or foot and the pain is made worse by
coughing or sneezing. As pressure is released from the nerve and the nerve
recovers, the pain subsides first from the back. The patient often refers to the
pain moving down the leg and flowing out through the foot. The history is one
of repetitive attacks with complete remission between them.
2.4 How does lumbosacral strain present?
The patient is usually male and aged between 25 and 50 years of age.
The pain is commonly at the top of the sacrum and often radiates to the front
and lateral aspect of the thigh. It tends to be related to a specific event or
activity, is exacerbated by bending forward and is much worse towards the
end of the day. Often, the patient is unable to lie flat on his back and flexes the
knees and hips to relieve the pain. Strains can be differentiated from a disc
lesion by the fact that the pain remains in the back or buttocks, whereas in a
disc lesion it radiates down the leg below the knee.
2.5 Which factors argue against a diagnosis of
‘benign’ back pain?
Pain which presents at extremes of age is cause for concern. When an
elderly person or young child presents with back pain there may well be a
more serious underlying cause than strain. Any associated features, such as
fever, malaise or headache, may suggest a systemic illness and deserve careful
investigation for infection or malignancy. A history of severe trauma (e.g. falling
from a considerable height) would necessitate a radiograph. Persistent neuro
logical signs and symptoms are also worrying. Severe continuous pain that
responds neither to rest nor to analgesia requires a more detailed examination
of the patient. Some neurological symptoms, such as paraesthesia, are rela
tively common, particularly with sciatica. Abnormalities of bladder or bowel
function or loss of muscle power, however, are far more sinister and would
require a diligent search for the underlying cause.
7
EAdiiiiriciiiuri
3.1 Examination of the patient with back pain
It is important to have a technique for rapid examination which allows
an accurate diagnosis to be made and reveals any underlying illness. Ideally, a
complete and thorough general examination and a full and detailed neurolog
ical examination should be performed on any patient with back pain. Unfortu
nately, a busy surgery and a waiting room full of patients often preclude this.
The extent of examination needed can generally be decided by the
history. An old lady who is normally uncomplaining but presents with sudden
onset of severe back pain should have a more detailed examination than a
young housewife who has many complaints including a vague back ache.
Selection of patients for examination is therefore assisted by a good history.
3-2 How is a rapid examination best
performed?
When the patient enters the surgery it is possible to make certain
observations. His gait, posture, movements and general discomfort are all
readily seen prior to and during the history taking. His seated posture and ease
of undressing and getting onto the examination couch are also easily assessed.
The patient should be fully undressed for a proper examination. His general
habitus, posture and spinal contour are observed. Scoliosis, kyphosis, loss of
lumbar curve and any tilt to one side are then noted. In a busy general practice
there may not be time for the patient to undress fully but he should at least
remove his shoes and climb onto the couch for examination. After standing for
examination of the back the patient is requested to return to the couch for
reflex tests. A patient with acute back pain will obviously find difficulty in doing
this, while the patient who is only attempting to impress the doctor with the
severity of the pain will leap back onto the couch to lie down!
Source of pain
The patient should be asked to point to the site of maximum pain. A
very tender point may indicate torn muscle tissue. It is useful to mark any
point of maximum tenderness and refer back to it later (see page 8).
Palpation
The muscles around the spine should be palpated; any muscle in spasm
will feel tighter than usual, and spasm may cause the spine to tilt towards the
affected side. Tenderness may be elicited over a particular area. Vertebral
percussion may reveal an area of bony tenderness, such as occurs from a crush
fracture.
8
THE PAINFUL BACK
Active movements
Flexion, extension, lateral flexion and rotation should all be tested
(Figure 3). Most true flexion occurs in the lumbar region, with little flexion in
the thoracic area. Most of the apparent flexion of the spine occurs at the
atlanto-occipital joints and at the hips.
9
THE PAINFUL BACK
THE PAINFUL BACK
Examination
The straight leg raising test is performed with the patient supine
(Figure 4). There must be no compensatory lordosis during the test; this is
excluded by the examiner placing a hand in the small of the back and lifting the
leg until the patient feels pain or a normal excursion is accomplished. If the
excursion is limited, the test is repeated and, just before reaching the
maximum height, the foot is dorsiflexed. This provides additional traction on
the sciatic nerve, and if pain is caused by this maneouvre it suggests irritation
of the nerve roots forming the sciatic nerve. Pain occurring at less than 40
degrees to the horizontal is probably due to impingement of the protruding
intervertebral disc on a nerve root. Pain occurring at a greater elevation is
probably due to tension on a nerve root which is abnormally sensitive, though
this is not necessarily caused by pressure from an intervertebral disc lesion..
Neurological examination
Any evidence of muscle wasting should be assessed. A dropped toe
occurs with lesions of the L5 nerve root which also innervates other
dorsiflexors of the foot.
The knee jerk is supplied primarily by L4 and is not often affected. The
ankle jerk (SI), however, is often lost or diminished in sciatica. Sensation to
light touch and pinprick should be assessed in all. cases of suspected sciatica
and in other cases where symptoms, such as paraesthesia, are present.
Dermatome distributions for the various nerve roots are shown in Figure 5.
Specific examination
Rectal and vaginal examinations and more extensive examination of
other systems should be carried out as appropriate. A general summary of
examination procedures is given in Figure 6.
3.3 What are the physical findings in a
prolapsed intervertebral disc?
Patients with prolapsed intervertebral discs often demonstrate a char
acteristic posture with a forward tilt and obliteration of the normal lumbar
concavity. The hip and knee joints on the affected side may be flexed. Muscular
spasm may cause a lumbar scoliosis. Lateral flexion in the opposite direction to
the tilt is resisted (actively and passively) and is painful. Despite the loss of
lateral flexion in that direction, the other movements will be pain free. The
spasm is usually in the sacrospinalis and is worse on the side of the lesion. Pain
radiates along the L4, L5 or SI dermatome depending on the site of the disc
lesion. Deep tenderness is often present 50 mm lateral to the mid-line and is
more pronounced on the side of the lesion. If pain is felt in the front of the
thigh, a protruding disc at L2,3 is suggested. The femoral stretch test (Figure 7)
confirms this if the patient lies prone and flexion of the knee on the affected
side reproduces the pain. The crossed leg pain sign is useful since patients are
seldom familiar with it. Those patients with a
disc and severe sciatica will complain of pain
side is raised. With a disc lesion this pain is o
leg. Thus, raising the unaffected leg causes pal
It
03558
THE PAINFUL BACK
5
Dermatome distributions
12
THE PAINFUL BACK
6 Summary of examination procedures
• Body habitus and posture
• Site of pain
• Palpation and percussion
• Active movements, to be performed standing and sitting:
flexion, extension, rotation, lateral movements
• Straight leg raising test and dorsiflexion of the foot
• Femoral nerve stretch test
• Sacro-iliac joints (palpation and appropriate tests)
• Neurological examination:
muscle tone, bulk and power
ankle and knee jerk
sensory disturbance
• General examination:
rectal and vaginal
raising on the affected side is more restricted by pain than raising the
unaffected leg. Weakness of the big toe extensor is common, as is loss of the
ankle jerk. However, progressive weakness or loss of both the knee and ankle
jerk is a reason for referral.
3.4 How can sacro-iliac disease be revealed?
Sacro-iliac disease is relatively uncommon. The sacro-iliac joint is
inaccessible except at one small point which is one finger-breadth medial to,
and one finger-breadth below, the posterior, superior iliac spine.
The patient is asked to point to the site of maximum tenderness.
Passive movements when standing reveal that flexion of the spine is performed
incompletely and with hesitation. The patient is asked to repeat the move
ment while seated and it is comparatively free in this position. Rotational
movement increases pain at the affected joint. Palpation is best achieved by
firmly placing the thumb just medial to the posterior iliac spine and asking the
patient to bend forward slowly. This opens the joint and causes tenderness.
The straight leg raising test is unimpaired by sacro-iliac disease. The
pump-handle test elicits pain at the sacro-iliac joint; in this test the leg is
grasped below the knee and the hip and knee joints are fully flexed. The flexed
knee is then directed firmly towards the opposite shoulder and pain is felt in
the affected sacro-iliac joint.
Common causes of sacro-iliac disease are strain, which is a benign
condition, and arthritis of the sacro-iliac joint, secondary to ankylosing
spondylitis, Reiter’s disease, inflammatory bowel disease or psoriasis.
13
THE PAINFUL BACK
3-5 What are the findings in lumbosacral
strain?
There is increased concavity of the lumbar spine and some spasm of
the spinal muscles during active movements of the spine. Forward bending is
limited when sitting and standing. Active movements involving the strained
muscles cause pain but passive movements do not. The straight leg raising test
can be performed on either side without restriction. If the patient is examined
lying prone, with four pillows beneath the pelvis, then the gaps between the
lower lumbar spinous processes are opened. The maximum tenderness is
either below or just above the L5 spinous process. There may be an acute
depression palpable between the normal intact ligaments and laxity of the
deranged ligaments.
3-6 What if there are no physical signs?
Many patients with chronic low back pain have no physical signs. These
patients often respond to simple methods of treatment and have normal
radiographs and blood tests. Occasionally, the radiographs may show a
condition which does not account for the pain (e.g. spina bifida occulta). If
simple measures, such as rest and analgesics, are unsatisfactory and the
patient’s lifestyle and job are threatened, he should be referred to a unit
specializing in back problems.
14
investigation
4.1 Which patients should have radiographs and
blood tests?
The need for radiographs and blood tests is determined on the basis of
the history and examination. In an elderly patient presenting with severe back
pain, multiple myeloma can be excluded by complete blood count (CBC), ESR.
electrophoretogram and assessment of Bence-Jones proteins. Also in elderly
patients, blood tests for calcium, phosphate and alkaline phosphatase may
commonly indicate Paget's disease, osteomalacia or secondary carcinoma.
The indications for radiographs are less clear-cut. A history which
suggests the possibility of crush fracture or other bony trauma obviously
warrants radiographic examination, but a study in the USA showed that, in
general, the risk and cost of a lumbar spine radiograph at the initial visit, in
patients with acute low back pain, do not justify the relatively small associated
benefit. The conclusion was that radiographs are only justified if the pain does
not improve in an 8-week follow-up period. However, it is generally felt that if
there is no improvement after a week of rest and analgesia, radiographs. CBC
and ESR should be carried out.
Cervical spine pain is a different matter and, if there is any possibility of
rheumatoid arthritis in a patient with neck pain, radiographs both of the
affected area and of the odontoid peg should be taken. Radiographs may be
normal in early ankylosing spondylitis and also in bony secondaries. A dramatic
finding, such as spondylolisthesis, does not necessarily mean that the cause of
pain has been found. Spondylolisthesis is the condition in which a vertebra has
slipped forward relative to the one below it. It is not. in itself, serious and may
have been present for a long time, with or without pain. If it does cause pain, it
responds to simple conservative measures. Lumbosacral anomalies are also
common. Spina bifida, transitional vertebra, lumbarization and sacralization do
not necessarily account for the pain.
A lengthy radiographic report should not deter the doctor from
initiating treatment because a large proportion of the report can probably be
interpreted as normal findings. For example, in older patients the changes may
be consistent with age. The term 'arthritis' should be avoided if possible and
the patient informed that his back shows signs of normal 'wear and tear'.
Once it is clear that the pain is not going to subside with conservative
measures and that further investigation is required, the patient should have a
CBC, ESR and plain radiographs taken prior to more expensive tests, such as a
myelogram or CT scan. In 9 out of 10 cases, radiographs of the lumbar spine
are normal, but the doctor often feels he must send the patient for radio
graphy to avoid the risk of medico-legal recriminations.
15
i ne iiidiinyei er
5.1 How can the malingerer be identified?
One of the most difficult problems for the general practitioner is that
there are some patients who use symptoms of back pain to gain compensa
tion. pensions, sympathy or time off work. Diagnosis of these ‘malingerers'
depends on finding positive features in the history and examination.
A detailed history often gives an indication of the underlying problem: a
patient seeking compensation from his employer can often give a long and
detailed history of how and why the pain occurred. The cause is generally
related to work and the patient relates with confidence the exact time and
date of the onset of pain. Such a history does not, of course, indicate that the
patient is definitely a malingerer, as pain can occur very acutely, and some
patients with true back pain are able to specify the precise time of onset of
their pain. Another type of malingerer, such as a middle-aged, depressed
woman, may present with vague lower back pain associated with many other
psychosomatic complaints (e.g. headache, tiredness, lassitude and poor sleep
ing habits). The malingerer often describes the pain as agonizing or unbearable.
but shows little sign of severe suffering.
In the course of the physical examination the patient should be asked
to touch his toes. If flexion is reduced, the patient should then be asked to sit
on the examination couch and to touch his toes with his legs straight. The
same movement is, of course, required in the two manoeuvres (Figure 8), and if
the patient successfully completes the second movement but not the first, he
may well be a ‘malingerer’.
16
THE PAINFUL BACK
Malingerers are often unable to pinpoint the site of pain accurately.
Inconsistencies can be detected by asking the patient to point to the site of
maximum tenderness, marking this spot, and then, after examination of other
organ systems, requesting the patient once more to identify the most tender
point. The two points are often widely divergent (Figure 9). The malingerer
may also move with a 'broken glass’ (jack and claim that movements in all
directions give severe pain; this does not occur in organic pain.
Even where malingering is suspected, investigation may be required to
exclude such disorders as malignancy, osteoporosis or ankylosing spondylosis.
It must be remembered, however, that malingerers are often very keen to have
surgery for their complaint and the ‘failed’ back operation may provide an
opportunity for medico-legal action.
Recurrent I-day absences from work ascribed to sickness and back
pain are associated with a particular personality type, and there is often a
tendency to lateness and accidental injury in such people. If back pain is
associated with emotional problems, the psychological aspect should be
investigated. It is worth bearing in mind that severe, continuous pain com
monly results in the patient becoming less emotionally stable than previously.
The doctor must therefore be confident that the pain is not as bad as the
patient asserts before he discounts it.
17
THE PAINFUL BACK
Conservative
management
6.1 How is acute back pain best managed?
Despite the fact that back pain may be severe, only a very small number of
patients will have a serious disease, such as a large disc prolapse, malignancy or
infection.
The initial treatment of choice for back pain is bed-rest, provided that
any severe underlying problem has been excluded and referred appropriately.
Bed-rest should be continued for 6 weeks before it can be deemed to have
failed. During this time the patient should be regularly assessed to determine
improvement or deterioration, and to make sure that no new treatment or
consultant referral is necessary.
Bed-rest should be total apart from toilet privileges; a commode
should be used if going to the toilet requires a walk up or down stairs. The use
of bedpans can cause problems as the pain may worsen when the patient tries
to get on and off them. The bed should be very firm with boards under the
mattress or, if necessary, the mattress should be placed on the floor.
Orthopaedic mattresses are probably an unnecessary expense, but postural
muscles jerk into action with each small movement on a soft mattress and this
causes severe pain. Supine bed-rest can cause deep venous thrombosis. The
patient should therefore be taught to move toes and feet regularly in order to
prevent this complication.
Cervical pain is best relieved by a collar, while low back pain may
benefit from a lumbar corset. If the patient must remain ambulant, a plaster
jacket may be useful; however, there is some controversy regarding this
approach to management. Heat treatment and a hot water bottle placed in the
lumbar lordosis may help to relieve the pain.
The role of physiotherapy remains controversial, though it is generally
agreed that recurrence of pain can often be prevented by teaching patients
lifting techniques and correct posture. Ultrasonography may give some relief.
Exercises are of little use while the patient has pain but, after the pain is
relieved, exercises to improve tone in the oblique abdominal musculature may
help to develop a natural corset. Back extension exercises may increase the
load on the lumbar spine and exacerbate the symptoms, but isometric
exercises that contract the abdominal and gluteal muscles may be helpful.
Traction may be valuable in reducing the disc pressure and may give
considerable relief. It requires strict bed-rest and is most easily carried out in
hospital. However, brief periods of traction at home in bed may sometimes be
useful and, to some extent, the patient can help himself at home by lying flat
on the floor and stretching the spine by working the hips and shoulders in
opposite directions.
Manipulation should be avoided in any potentially serious back lesion,
such as prolapsed intervertebral disc. However, in selected cases, dramatic
relief can be obtained and excellent courses in back manipulation have now
18
THE PAINFUL BACK
become available. (General practitioners without training in this area are well
advised not to attempt manipulation).
Osteopathy and acupuncture have a place in treatment and may
provide relief when other methods fail. The main problem with these methods
is that an important diagnosis may be missed through inadequate examination
and lack of knowledge.
6.2 Where can drug therapy help?
There are several classes of drugs that may help to relieve back pain. A
benzodiazepine, such as diazepam, is useful as a muscle relaxant to provide
relief of muscle spasm. Stool softeners may also be necessary. Anti
inflammatory drugs (e.g. fenclofenac or indomethacin) have a useful role in
conditions such as arthritis, severe muscle strain, or traumatic lesions of the
back. Local anaesthetic injection into tender areas around the back can also be
helpful, but this is a specialized technique, best left to the experienced.
The most common drugs prescribed by the general practitioner for
back pain are analgesics. In assessing the level of analgesia required, measure
ment of the severity of pain is best scored in terms of the patient’s disability.
rather than by his subjective pain assessment. Problems with the activities of
daily living (e.g. dressing and sleeping) are useful indicators of the severity of
pain while examination of the patient will provide important indications of the
degree of disability. Acute back pain tends to run a recurrent course, with the
episodes settling spontaneously in 80% of cases within 2 weeks.
Analgesia should be aimed at continuously adequate pain-relief with
minimal side-effects and inconvenience to the patient. Mild pain can often be
controlled initially with aspirin or paracetamol, especially if other appropriate
advice is given.
In patients with severe pain (e.g. in those with a prolapsed interverte
bral disc), mild analgesics, such as paracetamol, are inadequate. Stronger
alternatives (e.g. dihydrocodeine) should therefore be considered. The advent
of sublingual buprenorphine'", by virtue of its effectiveness and long duration of
action, has added significantly to the quality of analgesia available in such
circumstances. On a regimen of two doses during the day and one at night,
pain can often be completely controlled.
If buprenorphine or dihydrocodeine fail to control the back pain after a
reasonable trial, the patient should be reassessed and possibly referred to a
specialist. It is tempting for a general practitioner to resort to prescribing
intramuscular opiates for acute back pain, but they should be avoided, if
possible, because of the risk of addiction.
The most important consideration in choosing an analgesic is that it
should be appropriate to the level of pain experienced. Frequent reassessment
of the patient and the effect of the pain reliever is imperative. The analgesic to
be used in the patient with chronic back pain is, of course, different from that
prescribed for the patient who has an acute episode of pain from a prolapsed
intervertebral disc. Prescribing analgesics for a ’malingerer’ is a difficult prob
lem and it is crucial that a positive diagnosis is reached in these patients, rather
than a diagnosis of exclusion.
"Temgeslc®: Reckitt & Colman
19
THE PAINFUL BACK
Referral
7.1 When should a patient with back pain be
referred?
In general, acute pain which does not respond rapidly to rest, or chronic pain
which interferes with the patient's lifestyle, should be referred. The decision to
refer is therefore based on an accurate and detailed history and examination.
Obviously, a patient with myeloma, malignancy or severe rheumatoid arthritis
requires referral. Patients with ankylosing spondylitis should also be referred.
as should any case of sacro-iliitis which may be associated with psoriasis,
Reiter’s disease or inflammatory bowel disease. Sphincteric disturbance is a
true emergency and needs immediate referral.
Further investigations are warranted if the pain is severe (e.g. if it
interferes significantly with day-to-day activities); the history will suggest
appropriate investigations. A myelogram will reveal nerve root compression
and intradural abnormalities, though in one series in the USA, CT scanning was
shown to be equally effective.
If careful investigations (myelography. CT scanning, discography, facet
arthrography, ascending lumbar venography and electromyograms, as con
sidered appropriate by the surgeon) fail to allow a specific diagnosis to be
reached in a patient with back pain, then surgery is inappropriate. In this
situation the general practitioner usually has a patient for whom analgesics are
the treatment of choice. In some of the patients, repeated epidural injections
may be useful. A much worse problem is a patient who has had back surgery
which failed because of poor selection procedures.
20
THE PAINFUL BACK
Surgery
8.1 Which patients require surgery and what
techniques are applied?
Only a few patients are suitable for surgery. The criteria for surgery are
persistent pain, increasing or persistent neurological signs, and a definite and
specific diagnosis.
In disc prolapse and nerve root compression a wide laminectomy can
be performed in order to decompress the spinal canal. In some centres, disc
excision (either posterior or anterior fusion) is performed by an approach
through the laminae. In 9 out of 10 cases, this provides relief, even with a
prolapsed disc. Thus, patients for surgery must be selected very carefully.
Vertebral fusion for disc degeneration, as shown on a discogram, is
controversial, but may be performed either as an anterior fusion for one disc,
or a posterior fusion with internal scaffolding if there are several degenerative
discs. In facet joint osteoarthritis, partial denervation of the joint can result in
relief of pain.
21
THE PAINFUL BACK
prevention
9-1 Can anything be done to prevent back pain
problems?
Much back pain could be prevented by simple advice from doctors, practice
nurses and physiotherapists. There are also self help and back pain associations
throughout the country.
Back problems occur in patients who are unfit, who have poor posture.
or who bend and lift incorrectly. In sedentary workers, poor posture when
seated and inactivity account for a high proportion of back pain. High-heeled
shoes may also cause stress to the back. Pregnant women and those who are
obese are more likely to have problems and therefore weight reduction may
be necessary in some patients. Correct posture with head up and shoulders
straight is also helpful. Incorrect bending can be remedied by suggesting
patients bend from the knees and not the waist. Similarly, when lifting heavy
objects the main movement should be at the knees rather than by back
flexion.
Patients who already have back problems can be assisted with sup
ports. corsets, cushions in cars, correct seating and firmer beds. (Volvo car
seats are designed by a spinal surgeon, and there is a Pirelli inflatable car
cushion which can be adjusted to give maximum comfort).
The social effects of back pain should not be forgotten by the doctor.
These are very difficult to assess and include marriage problems, an inability to
participate fully in family life and problems related to occupation. Employment
problems and the resulting financial worries can cause difficulty. Ideally, the
patient should change a heavy manual job for one that is more convenient and
less physically demanding, but in the present economic situation is may be
difficult to do this.
22
THE PAINFUL BACK
Conclusion
This booklet has attempted to assist in the management and diagnosis of back
pain in general practice. There are three important points to remember.
• A good, concise history and examination are of paramount
importance.
• Most of the causes of back pain are benign and the majority of
patients will recover within a month with simple conservative management.
such as bed-rest, bed boards and analgesia.
• Referral to a surgeon or a specialist should be based on history,
examination and simple investigations. Cases in which back pain is prolonged,
is increasing or is associated with neurological signs should be referred.
Acknowledgement
We would like to thank John Dove FRCS, Orthopaedic Consultant at the Stoke-onTrent Spinal Unit, Staffs, UK for his help in the preparation of the manuscript.
23
ISBN 0 906817 56 0
Position: 2628 (2 views)