Clinical review of back pain: diagnosis and management

Diagnosis and management of low back pain, including classification of low back pain, the STarT Back questionnaire, red flags, and suitable analgesia.

Section 1 Epidemiology and aetiology

Low back pain (LBP) is common. It is the single largest cause of disability in the UK. 

Key reading for the diagnosis and management of LBP and radicular leg pain (sciatica) is given in the National Pathway of Care for Low Back Pain and Radicular Pain (2014). NICE has new draft guidance on this due to replace the existing CG88 shortly.

Episodes are often self-limiting, although up to 80% of patients report still having pain a year later.1,2 In UK general practice, 6-9% of adult visits are for LBP.1,2

An estimated 21.7m disability- adjusted life years worldwide are attributable to occupation-related causes of LBP.1,2

Men are more affected (62.5%) than women and there are major socioeconomic implications, estimated at up to $100bn annually.1,2

The cause of many LBP episodes is poorly understood and a biopsychosocial model is the basis for diagnosis and treatment. Most clinical guidelines result in 85-90% of patients not receiving a specific patho-anatomical diagnosis.1,2

Psychosocial factors are felt to be the best predictors of such outcomes as pain severity, functional disability, fear of movement and work loss.

The best predictor of a further episode of LBP is already having had one episode. Recurrent LBP is more common in women, with increasing age and in the presence of significant psychosocial distress. LBP in the under-20s and the over-55s is regarded as potentially more serious.

Classification of LBP

Simple, mechanical LBP

  • Mechanical pain with or without lumbar muscle spasm and sprains
  • Facet joint syndrome
  • Spondylosis and spondylolisthesis
  • Scoliosis (developmental or secondary to spondylosis)
  • Traumatic fractures
  • Recurrent or chronic mechanical low back pain

LBP with radiculopathy

  • Lumbar disc herniation
  • Lumbar spinal stenosis
  • Cauda equina syndrome

Metabolic

  • Osteoporotic fracture

Inflammatory

  • Spondyloarthritis and sacroiliitis
  • Septic discitis

Malignancy

  • Metastases
  • Multiple myeloma
  • Primary tumours of bone

Chronic widespread pain and fibromyalgia


Section 2 Making the diagnosis

Key to the assessment of LBP is the STarT Back tool which helps stratify care according to need and provides a formal assessment of inorganic features which are strong predicators of outcome. This approach has been shown to be clinically valuable and cost-effective, with high patient satisfaction rates.3

When assessing a patient with LBP, a thorough history is essential, enquiring about pain intensity, relationships to activity and rest, prior injury or similar episodes, occupation and family history of LBP.

LBP in those aged 20-55 years is commonly mechanical. Spinal stiffness with or without pain is common in older patients and usually associated with lumbar spondylosis.

Pain radiating to the buttock and worse on spinal extension may indicate facet joint related pain. A psychosocial history may indicate factors affecting pain severity and poor coping strategies. Use of the STarT Back tool is invaluable.

Morning exacerbation of pain and stiffness lasting >20 minutes may indicate an inflammatory cause (spondylitis and spondyloarthritis).

Features suggesting more serious pathology include lower limb pain and neurological symptoms (lumbar disc prolapse or severe spondylosis with or without spondylolisthesis), problems with urinary or bowel control, and/or saddle parasthaesia/numbness, progressive leg weakness (cauda equina syndrome), fever, malaise or weight loss with sleep disturbance (infection or malignancy). Any prior or current history of malignancy is important.

STarT Back, a simple questionnaire for prognostic screening in LBP, is designed to classify patients as low, medium or high risk (psychosocial factors). This approach has been shown to be clinically valuable and cost-effective, with high patient satisfaction rates.3

Physical examination should look for abnormal gait; significant hip osteoarthritis or leg length inequality may be contributing factors.

To examine the lumbar spine, stand behind the patient. Ask them to bend forwards with straight knees, extend backwards, flex sideways. Look for abnormal spinal curves - scoliosis (lateral), kyphosis (forward) or lordosis (backward).

Leg length inequality may cause scoliosis that decreases on sitting or lying down. Ask the patient to lie supine and look for any restriction of straight leg raising. This suggests a low lumbar disc prolapse. Examine the hip joint in flexion.

Ask the patient to lie prone and look for anterior thigh pain when flexing the knee (femoral stretch test). This indicates a high lumbar disc problem (less common). Palpate the spine and buttocks for tender areas. Perform a neurological examination if radicular leg pain is present.

Investigations

Radiological assessment is unnecessary for most adults aged 20-55 years with no red flags. Abnormalities detected on imaging do not correlate strongly with symptoms and may increase anxiety.

Definitive assessment of the lumbar spine is by MRI scan. In most cases of LBP this will not affect the treatment plan.

Red flags
  • Age >55 or < 20 years
  • Fever, malaise, weight loss
  • History of malignancy
  • Severe lower limb neurological symptoms with or without cauda equina symptoms
  • LBP not relieved even to some extent by rest
  • Immunosuppression

Section 3 Managing the condition

Treatment of LBP requires a multidisciplinary approach, with the goal of maintaining function and minimising disability.

In most cases, it is important for the patient to remain active within the limitations of their pain. However, the condition tends to recur and many patients who consult a GP about LBP will still experience symptoms 12 months later.

For simple LBP, analgesia and physiotherapy will suffice. The role of a good clinical exam and reassurance should not be underestimated. According to the STarT protocol, low-risk patients are given advice by a physiotherapist, medium-risk patients receive intensive physiotherapy and high-risk patients receive physiotherapy and help to overcome psychological barriers to recovery.

Analgesia

Paracetamol, compound analgesics and NSAIDs may be appropriate. Some patients benefit from muscle relaxants, such as low-dose, short-term diazepam.

Once the acute episode is over, the patient should be given exercise and lifting advice to try to prevent recurrence. Compliance is poor and exercise should be something the patient enjoys and will undertake in the longer term, such as swimming, walking, yoga and core stability exercises.

If the history suggests any red flags, urgent referral to an expert spinal service will be required. In the presence of acute neurological deficit (foot drop or cauda equina syndrome), the patient should attend A&E.

An acute disc prolapse usually presents with initial LBP. In a few hours or days (sometimes longer), the patient develops sciatica and severe pain, pins and needles and numbness in a dermatomal distribution (L5 and S1 are the most common) and sometimes weakness.

A short period of bed rest, often in the fetal position, can be beneficial. These patients usually require stronger analgesia and a short course of diazepam.

The timing of a spinal root canal or epidural injection, using local anaesthetic and steroid, is judged by the severity of the pain and the length of time it is taking to settle. Access to these procedures across the UK varies. The National Pathway provides excellent direction for the management of radicular leg pain.

In facet joint syndrome, the pain is unilateral or bilateral and radiates from the lumbar region to the buttock(s). It is usually worse on spinal extension or returning to upright from flexion.

The evidence base for imaging-guided facet joint injections is not strong. It is likely that NICE will limit these further in its upcoming guidance.

Surgical treatments

The role of surgery in the management of spinal disorders is a contentious area and very few patients will require a surgical opinion. Despite this, surgical referrals are increasing. A growing evidence base helps inform decision-making.

Surgical intervention has a role in the management of LBP in selected patients when less invasive measures have proved unsuccessful. Systematic reviews consistently show that the efficacy for complex non-surgical and surgical management are broadly comparable (non surgical management has lower risk and cost). Opinion remains divided and requesring a surgical opinion for the relief of LBP should be considered on a case by case basis. A surgical opinion is often warranted with significant pain, loss of function and a proven radiological abnormality, such as focal disc disease or instability. Fusion surgery for LBP is rarely curative and the recovery protracted.

There is very good evidence that surgery for those patients with persistent neurogenic claudication is superior to continued non-operative management, even if the surgery involves rigid fusion. There are compelling arguments in the elderly for decompressing without fixation.4,5

Sciatica is commonly managed conservatively and surgery should be reserved for disabling sciatica or that which does not settle with time and conservative management. The outcomes are good and the risks low.

Cauda equina syndrome is a neurosurgical emergency should be referred urgently to an A&E with access to spinal surgery and preferably 24 hour MRI access.

Section 4 Prognosis

Recurrence is a characteristic feature of LBP. In any given year, 6-9% of adults will consult their GP for LBP. Most (60-80%) still have some pain or activity restriction one year later.1,2

However, in most cases, reassurance, accurate clinical diagnosis and well-planned rehabilitation can effectively manage the problem.

After an acute episode of uncomplicated LBP, the prognosis is good for most patients. The best predictor of future LBP is a first episode, so it is best to offer postural and lifestyle advice from a physiotherapist.

Weight loss is also helpful. There may have to be changes in the patient's working practices.

Generally, increasing levels of physical activity are good for general and spinal health. Many patients can self-manage their LBP.

STarT Back helps to identify those patients who will require a more tailored approach to management.

More persistent chronic LBP associated with disability is common and is often associated with psychosocial distress, anxiety and depression.

Strong opioids are best avoided, but this is not always possible. If sleep is disturbed, a nocturnal dose of amitriptyline (5-20mg two hours before bed) can be helpful.

A combined physical and psychological approach (CPP), is appropriate for most patients with persistent pain and associated disability, (see CPP in the National Pathway).

Section 5 Case study

A previously fit 22-year-old male athlete presented to his GP with a history of several episodes of LBP and buttock pain, which appeared to be related to weight-lifting at the gym.

Each episode lasted a few weeks and was usually unilateral. Between episodes he was well.

He had been treated with short courses of analgesia and exercise advice from a physiotherapist and his trainer. However, the problem had become more frequent and not always related to physical activity.

The patient was taking about 30 minutes to get moving in the morning, because of pain and stiffness.

He volunteered that NSAIDs were more helpful than simple or compound analgesia. He also reported that his sleep was disturbed.

X-rays of the lumbar spine and sacroiliac joints were normal. An MRI with gadolinium eventually confirmed bilateral sacroiliitis.

He was developing anterior chest wall pain in the morning (costochondritis) and his neck was also affected. He was referred to a rheumatology unit.

Despite high-dose, slow release nocturnal NSAIDs, he deteriorated. As he fulfilled the NICE criteria for starting a biological agent, he was prescribed etanercept and remains well five years later.

The patient later found out that his father had also had severe spinal pain and stiffness, probably due to ankylosing spondylitis.

Section 6 Evidence base

Clinical trials

  • Hill JC, Lewis M, Bryan S et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-71.
  • Weinstein JN, Tosteson TD, Lurie JD et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006; 296(20): 2441-50.
  • Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis. Int J Rehabil Res 2014; 37(1): 2-8.

Guidelines

Online resources

Textbook

  • Waddell G. The Back Pain Revolution (second edition). Oxford, Churchill Livingstone, 2004.

By Jim Greenwood, spinal ESP (physio) and NIHR doctoral research fellow, and Dr Mike Shipley, honorary consultant rheumatologist, University College Hospital, London.

This is an updated version of an article that was first published in July 2014.

Take a test on this article and claim your certificate on MIMS Learning

References

  1. Hoy D, Brooks P, Blyth F et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014; 0: 1-7. doi: 10.1136/annrheumdis-2013-204428
  2. Vos T, Naghavi M, Lozano R et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2010; 380(9859): 2163-96.
  3. Hill JC, Lewis M, Bryan S et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-71.
  4. Lee CH, Hyun SJ, Kim KJ et al. Decompression only versus fusion surgery for lumbar stenosis in elderly patients over 75 years old: which is reasonable? Neurol Med Chir 2013; 53(12): 870-4.
  5. Kovacs FM, Urrutia G, Alarcon JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine 2011; 36(20): E1335-51.
  6. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006; 296(20): 2441-50.
  7. Phillips FM, Slosar PJ, Youssef JA et al. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine 2013; 38(7): E409-22.
  8. Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis. Int J Rehabil Res 2014; 37(1): 2-8.
Suggested further CPD activity

These further action points may allow you to earn more credits.

  • Organise an audit of patients with LBP in your practice and review their access to physiotherapy or surgical procedures.
  • Review NICE guidelines on LBP for an update on management.
  • Arrange to meet a physiotherapist and a specialist spinal surgeon to discuss a protocol for referring patients for surgical fusion.

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