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Lessons to be learned when back pain presents

Dr Tom Kennedy and Dr Vincent Williamson share six case studies showing lessons to be learned in identifying the causes of back pain

Case 1

A 65-year-old presents with acute chronic back pain. He was a roofer before he retired from work with chronic low back pain.

He smokes 15 cigarettes a day and admits to drinking an average of three pints of beer a day. He has not lost weight and does not complain of any leg pain, but says he has pins and needles in both lower legs.

He recently bent over to feed his dog and developed quite severe low back pain. Clinically he was very tender in the upper lumbar spine. Neurological examination revealed some evidence of a peripheral neuropathy.

General examination was normal apart from palmar erythema and a few spider naevi. Abdominal examination was normal. Investigations showed a normal full blood count and ESR, his renal and liver function was normal apart from a low albumin and a slightly raised globulin.

Lesson

New onset of acute back pain with local tenderness needs investigating ­ 20 per cent of men with osteoporosis have an identifiable cause. Alcohol is the most likely, but multiple myeloma and coeliac disease need excluding.

Case 2

A 75-year-old presents with pain in her legs on walking 100 yards.

It is eased quickly with rest and she can walk on for a further 50 yards. She finds herself bending forwards to ease her pain.

She does not suffer from cramp or complain of any change in sensation in her legs. Her bowel and bladder function is normal.

She has suffered from back pain over the years but this is not any different now. She has not lost weight. She stopped smoking five years ago when she had a heart attack.

Clinical examination revealed reduced spine movements by about 30 per cent in all planes. Straight-leg raising was normal, as was neurological examination. The foot arterial pulses were just palpable

Although a plain radiograph might be helpful, a spinal MR scan is indicated to look for spinal stenosis. This may be treated with subcutaneous calcitonin injections, an epidural or it may require decompressive surgery

Lesson

Not all 'sciatica' is due to nerve root compression. In the presence of normal peripheral pulses, spinal stenosis should be considered.

Case 3

A 45-year-old works as cleaner in a local factory. When using a buffing machine, it veers off to the left and she develops acute low back pain. She attends the first-aid room and is told to go home, rest and take painkillers. She reports that the next day she cannot move her back and is confined to bed. She just manages to get up to go to the toilet.

She is still in lots of pain eight weeks later and is receiving sicknotes. She demands referral to a specialist for a 'scan'. Examination reveals general spinal tenderness, all movements cause intense spinal spasms. Neurological examination is normal. A magnetic resonance scan is arranged which shows bulging of discs but no nerve root entrapment.

The potential pitfall in this case is that although the patient presents with back pain, following minor injury, she shows many of the features of non-organic low back pain as described by Waddell et al (see below).

Lesson

Remember the importance of the psychological aspects of mechanical spinal pain. These patients are very difficult to manage and early referral to a pain management team offers the best hope for alleviating the symptoms and the patient's return to gainful employment.

Case 4

A 70-year-old presents with a history of polymyalgia rheumatica for which he has received oral steroids and a bisphosphonate for two years. On reducing his prednisolone below 5mg he develops more pain and stiffness in his low back radiating round to his hips and thighs. He continues to lose weight and is not well.

Examination reveals a cachectic man but there are no abnormalities found on routine examination.

A full blood count and ESR reveal non-specific changes. The crucial test here is a prostate specific antigen (PSA) which was very raised. Radiographs show sclerotic bony secondaries but the key is the PSA indicating prostatic cancer.

Lesson

Keep in mind original diagnoses. It is likely that this patient had prostate cancer as the cause of his original PMR-type symptoms.

Case 5

A 23-year-old who works for a local arboretum presents with low back pain of gradual onset. He reports that there will be good periods when he has very little pain but is often stiff after periods of rest. The pain does not usually radiate to his legs, but his hips may be very stiff. He reports his father had some low back pain. As a child he had one episode of a swollen knee following an episode of diarrhoea.

A full blood count revealed a normochromic normocytic anaemia 11.2g/dl with a raised ESR of 65mm/hr. His lumbar spine radiograph is normal but there is some blurring of the sacroiliac joints.

Lesson

Fully investigate unusual presentations in young people. The issue of whether to do a HLA B27 test is contentious. Although many people feel it is of little value, a negative test suggests ankylosing spondylitis or sacroiliitis is unlikely. If it is positive, although this does not mean the person will develop inflammatory spinal disease, the chance is higher. Also the risk of developing reactive arthritis secondary to bowel or urogenital infection is also considerably higher and the patient should be warned of this.

Case 6

A 56-year-old presents with pain in the low back and severe unremitting pain in the tops of her legs. Activity does not affect it. She is not eating well because of the pain and has lost 14lb in the past two months. The pain is keeping her awake at night and she is beginning to lose confidence in control of her bladder. There is no past history of serious illness including malignancy. Examination including the abdomen was normal. Neurological examination of the lower limbs was also normal to power, tone, light touch and reflexes.

A full blood count was normal and the ESR was 35. Routine renal, bone and liver biochemistry was normal. A plain radiograph of the pelvis was reported as normal. A MR scan of the pelvis showed a solid tumour arising from the sacrum which a biopsy showed to be a neurofibrosarcoma.

Lesson

This case demonstrates a number of red flag indicators (see below) and therefore needs

full investigation, despite the normal examination. Intra-abdominal and pelvic pathology including malignancy and aortic or common iliac aneurysm may present with low back pain.

The features of non-organic

low back pain

(after Waddell et al)

1Axial compression -> pain ­ vertical loading on a standing patient's skull produces low back pain

2 Pelvic rotation -> pain ­ passive rotation of shoulders and pelvis in same plane causes low back pain

3 Resisted hip flexion

4 Non-dermatomal sensory loss

5 Superficial, non anatomic tenderness to light touch ­ skin squeeze (superficial pain), widespread tenderness

6 'Cogwheel' (give-way) weakness

7 SLR ­- discrepancy between findings on sitting and supine straight-leg raising tests

8 Overreaction ­ disproportionate facial expressions, verbalisation or tremor during examination

> 3 present = be wary of operating; non-organic features

According to Waddell et al, non-organic signs by themselves should not be equated with malingering or the presence of a psychological problem. Rather, the finding of non-organic signs should alert the clinician to the need for more comprehensive testing

(Waddell G et al. Non-organic physical signs in low back pain. Spine 1980;5:117-25)

Red flags for possible

serious spinal pathology

·Presentation under age 20 or onset over

the age of 55

·Violent trauma: eg fall from a height, RTA

·Constant, progressive, non-mechanical pain

·Thoracic pain

·PMH - carcinoma

·Systemic steroids

·Drug abuse, HIV

·Systemically unwell

·Weight loss

·Persisting severe restriction of lumbar flexion

·Widespread neurological signs and symptoms

·Structural deformity

Tom Kennedy is a consultant physician and rheumatologist at the Royal Liverpool and Broadgreen University NHS Hospital, and

Vincent Williamson is a consultant radiologist at Wirral Hospital NHS Trust, Wirral

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