Back Pain

Definition/diagnostic criteria Back pain involves pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds.

Epidemiology Back pain is a prevalent issue, affecting a significant portion of the population at some point in their lives. It accounts for a considerable number of GP consultations and is a leading cause of disability worldwide. The lifetime incidence of low back pain ranges from 58-84%, and chronic back pain affects 11% of men and 16% of women.

Diagnosis Diagnosis of back pain is primarily clinical. Mechanical back pain typically includes localised pain, muscle tension, or stiffness with or without sciatica.

Symptoms and signs that suggest a more serious underlying condition include:

• Non-mechanical pain: Pain not related to movement or posture.
• Medical history of cancer: (especially cancers which metastasise to bone) steroid use, HIV, tuberculosis.
• Feeling generally unwell: Unexplained weight loss, fever or UTI symptoms.
• Neurological signs or structural spinal deformity.
• Localised vertebral tenderness.
• Upper back pain: Specifically thoracic back pain as this has a higher association with spinal abnormalities and systemic illnesses.
• Indications of vertebral fracture: For example, trauma, especially in those at risk of fracture (e.g. osteoporosis), localised vertebral tenderness.
• Cauda equina syndrome: Findings such as urinary incontinence, saddle anaesthesia, loss of anal sphincter tone, major motor weakness in lower extremities, persistent neurological findings.
• Signs of abdominal aortic aneurysm: abdominal mass, vascular disease history, age over 60.
• Pancreatic cancer: Epigastric pain radiating to the back, weight loss, jaundice.

Investigations Investigations are not routinely required for non-specific back pain. Imaging, such as MRI or CT scans, is reserved for cases where specific conditions like spinal stenosis or sciatica are suspected, or when red flags are present indicating serious underlying pathology.

Treatment

• Non-pharmacological: Exercise programs, including stretching, strengthening, and aerobic exercises, are recommended. Physiotherapy for manual therapy and exercise advice.
• Pharmacological: NSAIDs are first-line for pain management, with weak opioids (short term) and paracetamol as an alternative when NSAIDs are ineffective or poorly tolerated.

Arrange specialist referral for people with acute severe sciatica or ongoing radicular pain (for consideration for an epidural corticosteroid/local anaesthetic injection) or when non-surgical treatment has not improved pain or function.

Prognosis The prognosis for mechanical back pain varies. Many individuals experience a significant improvement in symptoms within weeks, but a proportion may develop chronic pain. For sciatica, a significant number of patients may have persistent symptoms for over a year.