Back pain is one of the common musculoskeletal disorder in general population. More than 80 % of people have experienced some form of back pain in their lifetime. There are different causes for back pain like traumatic, congenital, metabolic, inflammatory, neoplastic etc. It mostly occurs in adult and geriatric population with a strong predilection towards the female gender.  Characteristic of pain varies according to cause. Mostly the diagnosis is clinical but certain laboratory test, X-ray, CT scan etc. might be helpful in confirming the diagnosis. Treatment is conservative unless otherwise indicated. Conservative management included physiotherapy, rest, traction, fractions etc.
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Introduction

Upright posture of a human being has its downside and back pain a very frequent phenomenon among human as result of their posture. According to a study, more than 80 % of people had experienced some form of back pain in their lifetime. Most of the back pain subsided without any intervention but among them, almost three-quarter of people experience back pain in future life also i.e. back pain a constant phenomenon and it recurs. It can be acute that is when the pain lasts for few day to month but when it last for more than 3 months it can be called as chronic back pain. These chronic back pain cases may present as acute cases.

Differential Diagnosis of Acute Back Pain

There have been several recognized causes of acute back pain. The pain can be of any kind- dull, severe, throbbing, pricking or radiating to your arms and legs. The pain can originate from different sources- it could be from bones, muscles, discs or joints. When the pain is sudden and stays for a short time, usually lesser than three months, it is known as acute back pain. Depending on the origin, back pain can be classified into different types: 

Congenital causes Traumatic causes Inflammatory causes
Spina bifida

Lumbar scoliosis

Spondylolysis

Spondylolisthesis

Transitional vertebra

Sprain, strain

Vertebral fractures

Prolapsed disc

Tuberculosis

Ankylosing spondylitis Seronegative spondarthritis (SSA)

Neoplastic Metabolic/ degenerative causes Miscellaneous causes
Benign

  • Osteoid osteoma
  • Eosinophilic granuloma

Malignant

  • Primary: Multiple myelomas, Lymphoma
  • Secondaries from other sites
Osteoporosis

Osteomalacia

Osteoarthritis

Functional back pain

Postural back pain

  • Protuberant abdomen
  • Occupational bad posture
  • Habitual bad posture

Epidemiology of Back Pain

Age

Most of the acute back pain cases occur in adult or geriatric people mostly inclined to the geriatric population. It is rare in children but if the present back pain is due to congenital causes or some organic disorders. In the adolescent, it is mostly due to trauma or posture related. In adult ankylosing spondylitis, disc prolapse etc. are common. Back pain in elderly due to degenerative or metabolic causes.

Sex

Acute back pain is common in the female population. Several risk factors like repeated pregnancy, hormonal changes after menopause, poor nutrition etc. increases the risk of back pain in the female population. Women generally tend to get obese in their middle age, so mechanical strain due to increase in weight can also cause acute back pain.

Occupation

Occupational work is routine to individuals but the lack of proper ergonomic and repeated activities can cause back pain. Most commonly seen in miners, heavy lifters, doctors, truck drivers etc. 

Clinical Features of Acute Back Pain

Pain

Site

The site may be anywhere from upper to lower back. It mostly varies according to cause or site of the lesion. Specific disc prolapses at different vertebrae can cause pain different region like cervical disc prolapse cause pain in upper back while lumbar disc prolapses at the lower back.

Onset

Onset is mostly sudden but some time chronic pain may present as acute pain aggravated by certain risk factors. Back pain due to trauma, sprain, etc. present as sudden onset while in degenerative diseases like osteoporosis, osteomyelitis pain can be insidious in onset but aggravated by sudden movement or over activities.

Localisation

Localized pain is generally due to injury to muscle and tendon but generalized pain almost always due to injury to deeper structures like bone. Sometimes there is a referred pain which is mostly due to nerve root compression.

Progression

Some condition like trauma/ prolapsed disc causes pain acutely and gradually decreases while pain due to arthritis or spondylitis pain is chronic but present acutely with sudden movement or activity.

Relieving or aggravating factors

Generally, back pains like all other pain are increased or aggravated by certain activities and relieved by taking rest. Some condition like seronegative spondyloarthritis and ankylosing spondylitis causes pain which is typically getting worse after rest, and the patient feels relieved after doing some activity.

Severe back pain at night that responds to aspirin may indicate a benign tumor.

When pain increases by standing to walk and subsides after taking rest it is mostly due to spinal stenosis.

Gynecological pathology of back pain is indicated when pain increases during menstruation. 

Associated symptoms

Stiffness

It is present in a condition which produces a high degree of pain. Sometimes it present as a main symptom like in ankylosing spondylitis where stiffness typically occurs in morning.

Pain in other joints

Some rheumatic diseases present with back pain only but careful investigation find that it is due to a condition in other sites/ joints.

Neurological symptoms

Paraesthesia, numbness, tingling sensation or weakness are associated feature in disc prolapse. It is mostly due to injury to nerve root by mechanical compression.

Extra-skeletal symptoms

Some time urogenital complaint, abdominal cramps, the gynecological problem may present as back pain.

Mental status

Psychological factors must be ruled out in back pain as patient with a condition like hysteria or malingering predominantly present acute back pain.

Examination and Investigations of Acute Back Pain

At standing position

A normal standing posture of a human being is indicated when natal cleft and the occiput are in the same line, the two shoulders are at the same level or in the same plane, there is symmetry in the location of lumbar hollows and pelvis is square. Patients presenting with back pain this posture is disrupted and one must look for scoliosis (sidewise bending of the vertebral column), kyphosis (forward bending of the vertebral column), lordosis (backward bending of the vertebral column), forward flexion of the torso on the lower limbs and pelvic tilt.

Spasm

Muscle spasm may be an imminent sign of acute back pain. It can be diagnosed by simple examination of back where the paravertebral muscle is prominent at rest and this prominence increases in size by slight movement.

Tenderness

Tenderness due to muscle or ligament tear are localized and easily demonstrated by palpation. Conditions like Fibrositis may have a trigger point or tender nodule. Pain originating from the sacroiliac joint may have tenderness localized to the posterior superior iliac spine.

Swelling

Tuberculosis of vertebrae or bone may present as cold abscess or a swelling.

Range of movement

Limitation of movement at spine is a prominent feature of back pain due to organic disorders. When a person bends at spine there is a natural curvature of spine but when patient present with back pain due to organic disorder there is a loss of natural curvature and spine looks straight.

At lying down position

Straight leg raising test

This is a test to detect nerve root compression.

Neurological examination

This helps in localizing the site of injuries. Mostly sensation, power, and reflexes of different muscles are checked in this.

Peripheral pulse

To exclude the vascular causes of back pain peripheral pulse should be palpated. Vascular claudication may present as acute back pain.

Adjacent joints

One must examine the adjacent joints like the sacroiliac joints and the hip joint as often back pain is due to pathologies in these joints.

Abdominal, rectal or per vaginal examination

This may be done wherever necessary to exclude the gynecological condition or abdominal factors. In young adults presenting with back pain, chest expansion must be measured to exclude any respiratory pathology or rib cage pathology.

Investigations of Acute Back Pain

Clinical examination of back pain is enough to find a cause or the diagnosis. Radiological investigation or another form of investigation generally of no use in the acute back pain of duration less than 3 weeks as it does not change the course of treatment. On the contrary, back pain lasting for more than 3 weeks, X-ray examination is required to differentiate from other causes. X-ray is just acted as an extension of clinical diagnosis. There are a number of other investigations like blood investigations, CT scan, bone scan, MRI scan, etc. One has to be very thoughtful in ordering these investigations. Order only when you think it is going to change your line of action, or if the clinical diagnosis is doubtful.

Blood investigations

Suspected malignancies, metabolic disorder, inflammatory disorder and even infections causing acute back pain can be differentiated by doing simple laboratory investigations.

Radiological examination

Modality Description
 X- ray Routine X-rays with an anteroposterior view and lateral view of lumbosacral spine is required for almost all patient with chronic back pain.

It can differentiate between various diseases like metabolic disorders, inflammatory condition, and tumor/ neoplasm.

Although routine X-ray can show nonspecific signs usually it is important to form a baseline. X-rays should be done after preparation of the bowel with laxatives and charcoal tablets.

 CT scan It shows the softest tissue and bony problems around the vertebrae and spinal canal. It less invasive and replaced the more invasive procedure like myelography.
 MRI scan Prescribing for an MRI scan should be done carefully as it is an expensive investigation. It is better than CT scan in the delineation of soft tissue and even bone related problem. It is needed only in few cases.
Bone scan It may be helpful if a benign or malignant bone tumor is suspected on clinical examination but is not seen on plain X-rays.
 Electromyograph Nerve root compression due to disc prolapse can be diagnosed by electromyography (EMG).
 Bone scan It may be helpful if a benign or malignant bone tumor is suspected on clinical examination but is not seen on plain X-rays.

Treatment of Acute Back Pain

Although there are several causes for back pain, most of the back pain are non-specific. If pathological conditions causing back pain are diagnosed then treatment prescribed according to specific condition diagnosed but when back pain is due to non-specific causes then a set programme of treatment is requires. Mostly conservative treatment is prescribed to such patients. It consists of drugs, spinal exercises, rest, traction, hot packs, corset and education regarding the prevention of back pain.

Treatment of specific conditions

If any specific disease has been diagnosed by different diagnostic modalities, the aim after general conservative measures is to treat the specific cause, either medically or surgically based on the severity of symptoms, indications, and complications of the disease.

Treatment of non-specific back pain

Rest

In acute condition, absolute bed rest with a simple mattress is generally advised for one to two weeks. Absolute bed rest for more than three weeks is of no value rather general mobilization using supportive aids is warranted for a better result.

Drugs

Analgesic like NSAIDs, anti- inflammatory drugs and sometimes muscle relaxants are needed to reduce the pain. Medical treatment of specific pathologies may be prescribed after the diagnosis.

Physiotherapy

Hot packs, ultrasonic wave, shortwave diathermy are the modalities of choice in physiotherapy and gradually, a spinal exercises program is started.

Traction

It is given to a patient with back pain with a lot of muscle spasm. It also sometimes helps in ‘forcing’ the patient to rest in the bed.

Use of corset

This is used as a temporary measure in treating acute back pain, in back pain due to lumbar spondylosis, etc.

Education

Patients must be taught what they can do to alleviate the pain and to avoid injury or re-injury to the back. This includes education to avoid straining the back in activities of daily living such as sitting, standing, lifting weight etc. ‘Back Schools’ are formalized approach to this education.

Approach to a Patient with Acute Back Pain

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