Not a simple case of lower back pain

GPs' judgment on unresolved backache must be trusted, says Dr Keith Barnard.

I always liked Mr Lambert - he was one of those patients who always wore a smile and didn't come in for nothing.

At 73 years of age he was really fit and active with no history of serious illness. So it was concerning when he came along with a persistent backache that he said started a week earlier when he slipped on the stairs to his flat and jarred his back.

I saw him at the surgery and he was obviously struggling, but his examination was unremarkable. These days we are encouraged to advise a brief period of rest and rapid mobilisation, and of course, not to request an X-ray for back pain, an offence punishable by a long, lingering death at the hands of the local trust.

So as there was little to find, I advised a day or two's rest, prescribed some anti-inflammatories and told him to mobilise as soon as possible.

It was something of a surprise, therefore, when Mr Lambert's name appeared in the visit book 10 days later with a message that his pain was much worse. Had it been anyone else, I would have doubted the need for a visit, but this was out of character for him.

Mr Lambert lived alone and when I arrived, he was lying on his bed, unshaven, looking a little dehydrated, and in considerable distress with pain on the slightest movement. He had been unable to get out of the house, and was struggling just to get to the kitchen to make himself a cup of tea.

I examined him and found little to go on. There was some tenderness around his lower back, particularly in the L1 and L2 area but straight leg raising was normal and there was no referred pain into either leg.

He had been taking a paracetamol and codeine combination because the ibuprofen I had prescribed didn't help - but all this did was make him constipated.

This is the sort of situation GPs find most frustrating. Gone are the days when you could arrange a mobile X-ray at home, and persuading a house officer to admit someone with backache is like climbing Everest without oxygen. But I could not leave the poor chap where he was, and to make it all the harder, I didn't have a diagnosis.

I decided to speak to the doctor who ran the medical assessment unit, whom fortunately I knew quite well. We discussed possibilities such as spinal secondaries from a silent prostatic cancer, multiple myeloma and, despite the lack of a suggestive history, a compression fracture of the spine.

But it was my personal knowledge of my patient as someone who was not a lead-swinger that decided things in his favour, and it was agreed that he would go to the unit where they would consider what I thought was the now all-important investigation - an X-ray of his lumbar spine.

X-ray findings
When the report came back from the hospital, I felt I had been justified in using my powers of persuasion. Mr Lambert had a severe compression fracture of his second lumbar vertebra. The cause was probably his stumble on the stairs, because, although this was a minor trauma, he had a marked degree of osteoporosis.

As with about half of cases of osteoporosis in men, no reason could be found for Mr Lambert's thinned bones. He was started on alendronate and after a few days his pain began to settle and he returned home with a care package that made sure he was properly fed and watered. It took time for the pain to settle completely, but I was delighted to see him at the surgery a couple of months later, back to his old smiling self.

Dr Barnard is a former GP in Fareham, Hampshire

Lessons learned

  • Don't be bullied into not obtaining an X-ray of the lumbar spine if your clinical judgment says it is fully justified.
  • Remember that osteoporosis does occur in men.
  • Causes of osteoporosis in men include genetic factors, hypogonadism, steroid therapy, alcohol abuse, smoking and lack of physical activity.

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