1. How to approach a patient
with low back pain
DONE BY: Al-Yaqdhan Al-Atbi
Senior clerckship student
SQUH

2. •
•
•
•
History
Physical examination
Investigations
Management

3. Case …
Mr. B is a relatively healthy 37
years old male. While working in
his yard, he experienced intense
lower back pain that prevented
him from doing any more work.
He used some ibuprofen for pain
relief and spent the remainder of
the day resting. The next morning
he had increased muscle stiffness
and was not feeling any better, so
he come to see you.

4. What do you want to ask Mr.B?

5. • Personal data
• Present complain

6. Present complain
•
Onset & how it start :
•
•
•
•
acute or chronic
What were you doing just before the pain began?
Did you have a particular injury or accident?
Character:
Sharp, dull, throbbing or burning ??
•
Location & radiation:
•
•
lumber strain .. Paraspinous muscles- buttock
Herniated disc .. Below the knee

7. Present complain
• Duration
• < 6wk  Acute
• 6-12 wk Subacute
• > 12 wk  Chronic
• Intensity
• How it effects daily activity?
• Interfere with sleeping, walking or driving ?
• Associated symptoms
• stiffness, urinary or abdominal symptoms ??

8. Present complain
• Aggravating factors
• Valsalva maneuvers
• Sitting
• Walking down-staires
• Relieving factors
• Medication
• Non-pharmacologic measures ( massage, stretching,
heat or ice)
• Certain position.

9. MR. B
He describe the pain as dull and
burning. There is some radiation
into the left buttock. Prolong sitting
or moderate activity aggravate the
pain. He can get relief when he lies
down. He has never had back pain
like this.

10. Systemic review
•
•
•
•
•
•
•
Fever ??
Appetite/ wt loss?
Abdominal pain?
Cough/ sputum?
Bowel habits?
Dysuria, Hematuria?
Menestural history?

11. past medical history
• Medical & surgical history:
–
–
–
–
–
–
Previous trauma
Kidney diseases
Previous back pain, therapy
Malignancy
Disc prolepses—surgery
Female---obstrict diseases
• medication??
• Corticosteroids , immunosuppressant

12. Family history
• Cancers
• Back pain
• Spondylarthropathies
Social history
• Current stresses
• Occupation:
• Work, job tasks.
• Activity level of the job
• Perception of the pain ,impact on life

13. In Evaluating Patient With Low Back pain Should
Remember :
• Determine that the pain is intrinsic to the back and not referred
from problem elsewhere.
• Rule out progressive and Life- threatening disease.
• Determine whether nerve root compromise is present or not.

14. Red flags
General
•Failure to improve after 4-6wk of
conservative therapy
•Unrelenting night pain or pain at rest
•Progress motor or sensory deficit
Cancer
•Age > 50
•History of cancer or current cancer
•Unexplained weight loss

15. Red flags
Infection
•Fever or chills
•Recent infection .. UTI or skin
•Immunosuppression
• IV drug use
Fracture
•Age > 50
•History of osteoporosis
•Significant trauma
•Chronic oral steroid use

16. Red flags
Cauda
Equina S.
•Urinary incontinence or retention
•Saddle anesthesia
•Decrease anal tone or fecal
incontinence
•Lower extremities weakness
AAA
•Age > 60
•Abdominal pulsating mass
•Pain at rest

17. Physical examination
•
•
•
•
General appearance
Vital sings
Back examination
Systemic examination

18. • GENERAL APPERANCE :
• Comfortable or not ?
• Sitting, standing or leaning on
something?
• Vital sing
• Record vital sings
• High Temp. ???

19. Back examination
•
•
•
•
look
Feel
Move
Special tests

20. Look:
• From side:
• evaluate spinal curvatures.
• From behind:
• Note any scars, swelling, erythema.
• Shape of the spine.
Feel:
• The spinous processes of each vertebra.
– Tenderness .. Fracture, dislocation , infection or arthritis
• Any step-offs
– in spondylolisthesis or forword slipping of one vertebra, which may
compress the spinal cord.
• Muscle spasm or tenderness
– degenerative or inflammatory process , prolong contraction from
abnormal posture or anxiety.
• Sacroiliac joint
– tenderness indicate sacroiliitis or ankylosing sponylitis

21. Flexion
Rotation
Extension
MOVE
Lateral bending

22. Special Tests
• Scobar’s test:
– measure forward flexion of the spine

23. Straight leg raising Test
• How:
• Ask the patient to lie down on their back.
• Have the patient completely relax the affected leg.
• Cup the heel of their foot and gently raise the leg
.
• Positive test:
– Sciatic pain at 30-70 degree
– Aggravation of pain dorsiflexion of
the foot
– Relief of pain by knee flexion

24. • The straight leg raising test.
• if positive indicates lumber nerve root compromise.
• The crossed straight leg raising test.
(pain radiate into opposite leg)
• if positive indicates disc herniation.

25. Examination of the lower limb
• Muscle strength:
• Hip:
» Flexion (L2, 3,4 )
» Adduction (L2, 3,4 )
» Abduction ( L4, L5, S1 )
» Extension (SI)
• Knee
» Extension at the knee (L2,L3,L4)
» Flexion at the knee (L4,L5,S1,S2 )
• Dorsiflexion ( mainly L4,L5)
• planter flexion (mainly S1).

26. Examination of the lower limb
• Deep tendon reflexes:
– The knee reflex (L2,L3,L4)
The Ankle reflex (S1)
The planter response(L5,S1)
• Gaite
• Walk on heel ( L5)
• Walk on toe (S1)

28. MR. B
•
•
•
•
•
Uncomfortable, prefer to stand.
Has full ROM excep for limited forward flexion
Tenderness on paraspinous muscles.
SLR & crossed SLR test are negetive.
Lower limb:
– Normal reflexes, strength and sensation.

29. • What investigations you will order
for MR.B ??

30. • MOST PATIENTS WITH LOW BACK PAIN DO
NOT NEED INVESTIGATIONS
-Majority not due to a serious underlying condition
-Most are self-limited
70% to 90% of acute Low Back Pain cases will
Resolve in 1 month

31. Investigations
•
1.
2.
3.
4.
Radiological imaging
X-ray
MRI
CT
Radionuclide (bone scan)
•
Laboratory tests

32. Plain X-ray
Are very commonly used for low back pain

33. Do not X-ray routinely
Required only if the pain is associated with red flag
signs, which indicate a high risk of more serious
underlying problems

34. Do not X-ray routinely
• EXCEPTIONS:
1. Young(<25) X-ray sacroiliac joint to exclude
ankylosing spondylitis
2. Elderly: to exclude vertebral collapse/malignancy;
history of trauma; ‘red flag’ signs

35. Plain X-ray
•
Useful to identify:
1.
2.
3.
4.
5.
6.
Trauma
Compression fractures
Dislocation
Degenerative changes
Check spinal curvatures
End stages of malignancies

36. Plain X-ray
• AP & lateral view of lumbosacral spine
• Not highly sensitive or specific
• Not rule out serious illness
• Not good at identifying muscles and ligaments

37. MRI
•
Provide more detailed images of soft tissues (disc & Nerve roots)
1.
2.
3.
4.
5.
6.
Spinal stenosis
Disc bulge
Spinal tumors
Infections
Compressive lesions
Cauda equina
Note :
-If red flags are present , MRI should be undertaken even if X-ray is normal.
-MRI is preferable to CT scanning when neurological signs and symptoms are present

38. CT-scan
•
1.
2.
3.
4.
5.
•
Most of boney spinal pathology
Trauma
Osteomylitis
Infection
Tumors
Cases where MRI is contraindicated
(e.g. pacemaker or metallic clips)
More radiation exposure

39. Radionuclide (bone scan)
•
Useful when radiographs of the spine are normal
but the clinical findings are suspected
1. Osteomyelitis
2. Bony neoplasm
3. Occult fracture
•
Unlikely to demonstrate bone changes when
radiographs and ESR are normal

40. Radionuclide (bone scan)
• More sensitive than radiography
in detecting :
1. Metastasis
2. Paget’s disease (metabolic, bone turnover)
3. ankylosing spondylitis (Inflammatory
condition)
1. Trauma
2. Certain tumors (osteiod osteoma= benign)

41. Laboratory tests
•
1.
2.
3.
Indications:
Red flag signs
Malignancies or Infections
Metabolic causes

42. Laboratory tests
• FBC
• ESR/CRP
• Others( HLA B27 Ag),(Ca2+,PO4,Alkaline
phosphatase)
• HLA B27 is a protein in WBCs
– If positive, possible ankylosing spondylitis (AS)
– HLA B27 positive without having AS
– 95% of AS sufferers are HLA B27 positive

43. Laboratory tests
Test’s result
Diagnosis
Raised CRP or ESR
Inflammation or malignancy
Raised acid phosphatase or
prostate specific antigen
Metastatic carcinoma of the
prostate
Raised alkaline phosphatase
Other bone metastases and
Paget’s disease
Myeloma
Monoclonal band on serum
immunoelectrophoresis and
presence of urine light chains

44. • How to treat MR.B ??

45. Treatment
Symptomatic treatment
• Aims to:
1. Relive pain
2. Improve quality of life
3. Treat underlying cause

46. Non-pharmacological
• Explanation
• Reassurance
• Advice on exercise
• Simple analgesics

47. Pharmacological
•
Regular analgesia and/or non-steroidal antiinflammatory drugs (NSAIDs) may be required
to:
1. Improve mobility
2. Facilitate exercise

48. Pharmacological
• Opiates can be used for severe pain (single dose)
• Tricyclic antidepressant drugs (analgesics+sleep &
mood)

49. Would you advice bed rest?
• Bed rest should not be advised
• Returning to normal activities as soon as possible
(reduce chance of chronic pain)

50. Complementary and alternative medicine
•
•
•
•
Acupuncture
Spinal manipulation
Massage therapy
Physical therapy
• Exercise

51. Knee to Chest
Hip Extension
Arm Lifts
Pelvic Tilt
Hip Rolling
Pelvic Lift
Back Extension
Hip Extension
Curl Ups
Lying Prone In Extension
Push Up

52. When to refer?
• No significant improvement in symptoms after 4-6
wks of treatment (reassess the treatment plan).
• To avoid misdiagnosis and unnecessary or
inappropriate treatments

53. Referral to spine specialist
•
•
•
•
Cauda equina syndrome
Intractable pain
Serious spinal pathology is suspected
Progressive neurological deficits

55. Risk factors
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•
•
•
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Prior history of back pain
Heavy lifting
Frequent bending
Twisting and lifting
Repetitive work with exposure to vibration
• Psychosocial issues

56. Prevention
•
•
Limited number of studies
Overall , effective strategies for preventing initial or
recurrent low back pain are lacking
• Education:
1. Instruction on proper lifting technique (not seem to
be helpful)
2. Coping with back pain and encourages activity
(small benefit)

57. Prevention
3. Back belt and lumbar support (not effective in
workers)
4. Most effective prevention strategy seems to be
physical exercise

58. compliant
Diagnosis
Differential diagnosis Referred pain
1- 42 yrs male, alcoholic has abdominal pain radiated to
the back.
2- 70 yrs old female known to have osteoporosis has h/o
trauma.
fracture
3- 50 yrs male has Fever, back pain unrelieved by bed rest
or remaining motionless.
Infection
4- 22 yrs male has Pain unrelieved by remaining
motionless and morning stiffness relieved by exercise
5- 54 yrs old female k/c/o breast Cancer on chemotherapy.
6- Acute onset of urinary retention or fecal
incontenence,loss of anal sphincter tone ,saddle
anasthesia,global/progressive lower extremity weakness
AS
Spinal ca.
Cauda equina
syndrome

59. References
• Philip D. Sloane, Lisa M. Slatt, Mark H. Ebell, Louis B.
Jacques, Mindy A. Smith. Essentials of Family
Medicine. Fifth edition
• Robin C. Fraser. Clinical Method .A general practice
approach. Third edition
• Davidson’s. principles & practice of medicine.
Twentieth edition
• Oxford handbook of general practice. Third edition
• Oxford handbook of clinical medicine. Seventh
edition