An approach to
back pain including
red flags
Spescare CPD Meeting
Thursday 11/08/22
Swakopmund
Alex van der Horst
Consultant Spine and Orthopaedic surgeon
Windhoek Central Hospital, Namibia
You Tube:
Dr Mike Evans’ video on Back Pain
Epidemiology
• 70% to 85% of all individuals will
experience lower back pain at some time
• 30% are referred to Ortho; 3% admitted;
0.5% operated.
• 90% LBP resolves in 6 weeks
• Equal frequency in males and females
• Low back pain occurs in all age groups
(35-50 most commonly affected)
• The prevalence of LBP has changed little
over the years, but the associated
disability has increased four fold since
the 1970s.
Primary Causes
• Muscle strain or ligament
sprain
• Facet joint arthropathy
• Discogenic pain or annular
tears
• Spondylolisthesis
• Spinal stenosis
Differential Diagnosis
• Classify according to age
• Always exclude systemic causes
• Malignances
- Pregnancies / Gynecological
- Uro / Genital causes
BACK ACHE: Children
Never get back ache → if present and persistent, always serious
Causes:
• Trauma
• Tumors
• Infection - Discitis
- Vertebral Osteomyelitis
BACK ACHE: Adolescents
• Postural
• Scheuerman’s disease
• Trauma
• Infections
Young Adults
• Disc disease
• Spondylolisthesis
• Fractures
• Scheuermann's disease
• Ankylosing spondylitis
BACK ACHE: Adults
20 – 40 years:
•Spondilolysis
•Spondilolysthesis
•Disc Lesions
•Ankylosing Spondylitis
•Infections
Older Adults
• Spinal stenosis
• Metastatic disease
• Osteopaenic fractures
• Infection
BACK ACHE: Older People
• Degenerative Conditions:
- Scoliosis
- Spondylolisthesis
• Spinal Stenosis
• Tumors / Malignancy
• Weight
• Osteoporosis
• Vascular – Aortic Aneurisms
How do we evaluate
the patient with LBP?
• History
• The differential diagnosis for spinal causes of back pain is
extensive... – how do you pin point the exact pain driver?
• Back pain with or without radicular pain?
• Extremes of ages?
• Trauma history?
• Night pain?
• Various extra-spinal conditions also can cause back pain
• Potential secondary gain issues…
“Spinal” Causes of Back Pain
• Structural • Inflammatory
• Ankylosing spondylitis
• Segmental instability • Rheumatoid arthritis
• Discogenic pain, annular • Tumors
tears • Primary
• Facet joint arthropathy • Secondary, myeloma
• Muscle strain, ligament • Endocrine
sprain
• Osteomalacia
• Spondylolisthesis • Osteoporosis
• Spinal stenosis • Acromegaly
• Fracture
• Hematologic
• Infection
• Sickle cell disease
• Discitis
• Vertebral osteomyelitis
“Extra-Spinal” Causes of Back Pain
• Visceral
• Renal calculus, urinary tract • Drugs
infection, pyelonephritis • Corticosteroids cause
• Duodenal ulcer osteoporosis and
• Abdominal or thoracic aortic methysergide produces
aneurysm retroperitoneal fibrosis
• Left atrial enlargement in mitral • Nonsteroidal anti-
valve disease inflammatory drugs may
• Pancreatitis cause peptic ulcer disease or
• Retroperitoneal neoplasm renal papillary necrosis
• Biliary colic
• Gynecologic • Musculoskeletal
• Etopic pregnancy • Hip disease
• Endometriosis
• Sacroiliac joint disease
• Sickle cell crisis
• Scapulo-thoracic pain
• Psychogenic
On Physical Examination
• Neurologic assessment
• Note any weakness
• The effect of position on symptoms and
exacerbating or relieving factors should
be noted •WADDELL Criteria
• Pain with Vertical compression
• Discrepancy-Informal & Formal
• Physical examination testing
• Observe the patient closely while walking
and during transfers, noting any pain, • Hyper reactivity
antalgia, or ataxia • Paradoxical SLR test
• Perform a meticulous neurologic • Non-Dermatome loss Sensation
examination and note any
inconsistencies
• Always perform provocative testing (eg,
straight-leg raise, femoral stretch test)
BACK PAIN
conservative management
PERSISTENT PAIN
DEVELOPING NEUROLOGY
red flags imaging lab tests
Red Flags
Red flags are possible indicators of
serious spinal pathology:
•Thoracic pain
• Fever and unexplained weight loss
• Bladder or bowel dysfunction
• History of carcinoma
• Ill health or presence of other medical illness
• Progressive neurological deficit
• Disturbed gait, saddle anaesthesia
• Age of onset <20 years or >55 years
What imaging should I
request?
• X-rays
• AP(supine) & Lateral(standing)
• If pain > 6 weeks
• Earlier if you suspect malignancy or
infection
• Note coronal and sagittal alignment as well
as the presence or absence of disc
degeneration, osseous or soft-tissue
abnormalities
• Oblique (foraminal or radicular symptoms)
• Flexion and extension views
(spondylolisthesis or suspected
ligamentous instability)
Why should we NOT rely too
much on imaging studies?
If under age 60 and pain free:
Low yield: unexpected X-ray
findings 1: 2500
MRI:
bulging disc in 1 of 3
herniated disc in 1 of 5
•Over age 60 and pain-free:
•MRI:
–herniated disc in 1 of 3
–bulging disc in 80%
–all have age-related disc
and facet joint degeneration
–spinal stenosis in 1 of 5
cases • Imaging can be misleading: many abnormalities
as common in pain-free individuals as in those
with back pain
Why to request further
imaging…..MRI
• demonstrates spinal soft-tissue anatomy
better than any other imaging modality
• used as an adjunct to the history and
physical examination; a decision to operate
should not be based solely on MRI findings
• should be obtained in cases of suspected
malignancy, infection, and in cases of
isolated back pain unresponsive to
nonsurgical care for 3 months
Why to request further
imaging…..MRI
• indicated for patients who present with or
develop focal or diffuse neurologic deficits
• NOT indicated in most patients who present
with painful lumbar radiculopathy until they
fail 6 weeks of non-surgical care or they
deteriorate clinically (i.e. progression of
pain, development of neurologic deficits)
• indicated in patients who present initially
with intractable leg pain and are thus unable
to proceed with non-surgical management
Further evaluation
• Goal is to discriminate between “benign” cases
and disorders that require further diagnostic
studies
• Radiological imaging: X-ray / CT Scan / MRI
• Useful lab tests:
• FBC, ESR, CRP
• Calcium, ALP
• protein electrophoresis, BJP
Types of Back Pain:
Discogenic back pain:
• Pain from the innervated ligamentous
layer of the annulous fibrosis when it is
stretched with a bulging disc
• It is midline & worse with lordotic
postures, bending & lifting
Types of Back Pain:
Radicular back pain:
• Pain extending to the buttock and / or
leg
• Associated with disc herniation or spinal
stenosis or intra-spinal pathology
Types of Back Pain:
Referred back pain:
• Aortic Aneurysm
• Visceral (ulcer, PID, endometriosis,
gallbladder disease, pleural disease)
• Infection
• UTI, PID
• Hip Arthritis
Types of Back Pain:
Iatrogenic back pain:
• Dural adhesions
• Post surgical instability
• Post operative discitis; arachnoiditis
Types of Back Pain
Psychogenic back
pain:
• Must exclude •WADDELL Criteria
organic pathology
• Pain with Vertical compression
• Discrepancy-Informal & Formal
• Waddell's testing
inappropriate signs • Hyper reactivity
often present • Paradoxical SLR test
• Non-Dermatome loss Sensation
Main Causes of Low
Back Pain
• Degenerative Disc Disease
• Disc Herniation
• Spinal Stenosis
• Spondylolisthesis
Key Points about low back pain
• 90% are due to mechanical causes and will resolve
spontaneously within 6 weeks to 6 months
• Pursue diagnostic workup if any red flags found during
initial evaluation
• If ESR elevated, evaluate for malignancy or infection
• In older patients initial X-ray useful to diagnose
compression fracture or tumour
Key Points about low back pain
• Bed rest is not recommended for low back pain or
sciatica, with a rapid return to normal activities
usually the best course
• Back exercises are not useful for the acute phase
but help to prevent recurrences and treat chronic
pain
• Surgery is appropriate for a small portion of
patients with low back pain
CONCLUSION
• Not all backaches are
Prolapse Disc
(Correct Ddx)
• Don’t miss Pathological
Processes
(History, XR, Blood tests)
• Don’t over Investigate i.e. MRI
scan
QUESTIONS
