Up to 60% of the population will experience back pain at some time. Only about 20% of people with low back pain consult a GP each year. Acute back pain is however one of the commonest reasons for GP emergency appointments.1 An average GP sees about 70 presentations of low back pain annually.
About 6% of adults over 45 years and 4% under 45 are disabled by chronic low back pain. Back pain is the biggest contributor to work absence. If the pain becomes chronic it can lead to significant disability, depression and irritability, and can interfere with work and social functioning.
A 42-year-old hospital porter explains that he has been experiencing low back pain for the last 3 days. The pain was triggered by pushing a heavy trolley. It worsens with movement. There is no radiation or associated symptoms. He has had 2 similar episodes within the last 18 months which have both led to 6 weeks’ absence from work.
Contents
Assessment
Most low back pain presented to a GP is ‘non-specific’ or ‘mechanical’ back pain, which is pain not attributable to a recognisable specific pathology such as infection, tumour or osteoporosis.
Assessment aims to identify patients with non-specific back pain and to identify underlying pathology.
History
The history should ascertain the following features of back pain: onset, duration and progression; whether the episode is isolated or recurrent; site of pain and any radiation; and trigger factors. It is also important to ascertain the patient’s ideas (e.g. do they have theory of causation? , concerns (e.g. about the impact of pain on function) and expectations (e.g. about the likely duration of the pain).
Non-specific back pain may be acute or chronic. It is typically in the lumbar region and with nerve-root irritation; there may be associated pain in the leg (sciatica). The pain often varies with posture and with time. It may be exacerbated by movement, and patients often describe a specific trigger, such as lifting a heavy object. The main features of secondary causes of back pain are summarised in table 1.
Table 1 features of secondary back pain
| Condition | History | Examination/investigation/referral |
| Prolapsed intervertebral disc – nerve root compression |
-Leg pain ‘sciatica’ | -Reduced straight leg raising |
| Central disc prolapsed – cauda equina syndrome | -saddle anaesthesia -bowel/bladder dysfunction |
-ESR -Joint examination -Referral to rheumatology |
| Ankylosing spondylitis | -Young men -Night pain -Morning stiffness -Symptoms >3/12 |
-ESR -Joint examination -Referral to rheumatology |
| Bone metastases | – Older patients – Primary malignancy -Worsening pain |
-PSA -Calcium -Prostate examination |
| GI or GU pathology (peptic ulcer, pancreatitis, pyelonephritis, renal stones) | -Unrestricted movement -No association with movement |
-Urinalysis -Urology -Imaging referral to specialist |
Examination and investigation
Examination should be guided by the history. For example, in prolapsed intervertebral disc, neurological examination of the legs might show reduced reflexes or diminished sensation. If prostatic carcinoma is suspected, rectal examination should be carried out. Most cases of non-specific back pain require no investigation, and X-rays are rarely helpful.
Management
Patients with secondary back pain will be managed according to the cause and it is likely that they will need to be referred to an appropriate specialist. Non-specific back pain is managed by GPs. Aims of management are to (i) alleviate the acute symptoms and (ii) minimise the risk of the patient developing chronic pain with the associated psychological, occupational and social consequences.
Management of the acute episode
- Offer verbal and written information about low back pain (the Back Book)2
- Advise about self-management
- Encourage patient to continue with normal activities
- Analgesia
- Muscle relaxant, if spasm present
- Advice about recognising ‘red flags’
- Refer for advice from physiotherapy
Recognition of red flags
Urgent referral to a neurosurgeon is required if there are ‘red flags’:
- Progressive, persistent or severe neurological deficit
Bladder or bowel dysfunction
Prevention of chronic symptoms and disability
The risk of back pain becoming chronic can be assessed using a validated questionnaire3 (available as an on-line tool), which incorporates psychosocial risk factors (figure 1). Patients are classified as being at ‘low’, ‘medium’ or ‘high’ risk, and their risk status determines their management. If the patient is at high risk, they should be managed as above, but also be offered more intensive physiotherapy, cognitive behaviour therapy (CBT) and if appropriate, occupational health advice.
| Keele STarT Back Screening Tool | Yes | No |
| Has your back pain spread down your leg(s) at some time in the last 2 weeks? | ¤ | ¤ |
| Have you had pain in the shoulder or neck at some time in the last 2 weeks | ¤ | ¤ |
| Have you only walked short distances because of your back pain? | ¤ | ¤ |
| In the last 2 weeks, have you dressed more slowly than usual because of back pain? | ¤ | ¤ |
| Do you think it’s not really safe for a person with a condition like yours to be physically active? | ¤ | ¤ |
| Have worrying thoughts been going through your mind a lot of the time? | ¤ | ¤ |
| Do you feel that your back pain is terrible and it’s never going to get any better? | ¤ | ¤ |
| In general have you stopped enjoying all the things you usually enjoy? | ¤ | ¤ |
Overall, how bothersome has your back pain been in the last 2 weeks?
| Not at all | Slightly | Moderately | Very much | Not at all |
| ¤ | ¤ | ¤ | ¤ | ¤ |
Chapter 5 1 NICE. CKS Back pain – low (without radiculopathy) https://cks.nice.org.uk/back-pain-lowwithout-radiculopathy Chapter 6 2 Roland, M, Waddell G, Klaber Moffat J, et al The Back Book: the Best Way to Deal with Back Pain 8 Jul, 2002 Chapter 7 3 Mallen, CD, Peat, G ,Thomas E et al. Prognostic factors for musculoskeletal pain in primary care: a systematic review. Br J Gen Pract 2007;57(541):655-661. References
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