Back Pain

Introduction

Back pain is defined as pain along the spine stretching from the neck downward and including the buttocks area.
It affects the cervical, thoracic, lumbar, sacral and coccyx spines.
It is probably the commonest affliction of
mankind.
It affects all ages groups and sex
Low Back pain is the commonest form
Most cases are due to mechanical causes
-poor posture, overuse, unaccustomed
exercises.
Most back pain are from the soft tissues of the back viz, muscles, ligaments, tendons, and not from the bony or joint structure.
Most back pain will resolve within six weeks with or without treatment, hence there is no need to investigate most cases of back pain.
It could however be recurrent.
There are ‘Red flag’ clinical features that
necessitate further investigations (X-ray, MRI, CT).
These include:

  • Back pain that disturb sleep
  • Back pain that persists with recumbent position
  • Back pain associated with constitutional disturbances such as fever, loss of weight, nausea, and general feeling of being unwell.
  • Back pain associated with bowel disorders.
  • Back pain associated with urinary symptoms.
  • Back pain associated with muscle weakness
  • Back pain associated with deformities of the back.

Other causes of back pain apart from mechanical include:

  • Degenerative Arthritis- spondylosis.
  • Spinal canal stenosis
  • Spondylolisthesis
  • Osteomyelitis
  • Primary or secondary malignancies
  • Osteoporotic fracture
  • Multiple myeloma
  • Tuberculosis of the spine
  • Spinal abscess

Clinical features

  • Back pain
  • Back Stiffness
  • Radicular pain in the arms or legs
    is suggestive of disc lesions
  • Saddle anaesthesia
  • Paraesthesia in the feet
  • Back pain worsened by coughing or sneezing
  • Back deformity

Differential Diagnosis

  • Referred pain from gastro-intestinal structures, liver, gall bladder, pancreatic disease.
  • Aortic aneurysms
  • Tumours of the pleura, pericardium
  • Pelvic inflammatory diseases
  • Psychosomatic disorders.

Investigations

  • None if the pain is mechanical
  • Laboratory investigations to exclude other causes
  • Imaging- Plain X-rays, CT Scan, MRI, Bone Densitometry, Radioisotope studies

Treatment Objectives

  • Relief of pain
  • Treatment of underlying disease
  • Treatment of complications

Management

  1. Non Pharmacologic:
    • Weight loss
    • Avoidance of precipitating factors
    • Physical therapy
    • Acupuncture
    • Bio feed back
    • Back exercises e.g. Mackenzie
    • Extension
    • Exercises.
  2. Pharmacologic

Simple analgesics- Paracetamol up to 1gm tds, with or without

  1. Non steroid Anti-inflammatory drugs
    • e.g. Ibuprofen up to 2,400mg dly,
    • Naproxen 500mg BD,
    • Diclofenac -75mg BD,
    • Cox 2 inhibitors Celecoxib 200mg daily.
  2. Muscles relaxants
    • Tizanidine – up to 4mg tds,
    • Baclofen 5-10mg daily
  3. Narcotic analgesics
    • Tramadol- 50mg tds,
    • Morphine – Opioid-naive patients: 15-30 mg PO q4hr PRN
  4. Codeine based compounds
  5. Anti depressants
    • ¬†Amitriptyline 25 – 50mg nocte
  6. Selective Serotonin Re-uptake inhibitors
    • e.g. Fluoxetine
  7. Anti-convulsants
    • Pregabalin – up to 600mg daily
    • Gabapentin- up to 1,500g daily.

Notable adverse effects, caution and contraindications

NSAIDs

  • Individuals vary in their responses –
  • Should not be taken on empty stomach because of increased risk of gastric erosions and bleeding
  • Particular caution in the elderly; paracetamol is very useful in treating pain of mild to moderate severity
  • Combinations of different NSAIDs increases gastro toxicity without conferring any advantage
  • Interaction with antihypertensive medicines may lead to poor blood pressure control
  • Interaction with warfarin: increased risk of bleeding

Morphine

  • Nausea and vomiting; constipation; drowsiness; difficulty with micturition; biliary spasm; hypotension
  • Dependence