Back Pain: Assessment and Management for PLAB 1
Back pain is a common presentation in primary care and a frequent topic in medical licensing exams like PLAB. Effective assessment and management require a systematic approach, considering red flags, differential diagnoses, and evidence-based treatment strategies aligned with UK guidelines.
Initial Assessment: History Taking
A thorough history is paramount. Focus on the onset, duration, character, location, radiation, aggravating and relieving factors, and associated symptoms. Crucially, inquire about 'red flags' that suggest serious underlying pathology.
Red flags include: fever, unexplained weight loss, history of cancer, severe or progressive neurological deficit, cauda equina syndrome symptoms (saddle anaesthesia, bowel/bladder dysfunction), significant trauma, IV drug use, immunosuppression, and pain worse at night or unrelieved by rest.
Physical Examination
The physical examination should include observation, palpation, range of movement assessment, neurological examination (motor, sensory, reflexes), and specific provocative tests. Assess gait and posture. For neurological deficits, evaluate motor strength (e.g., hip flexion, knee extension, ankle dorsiflexion/plantarflexion), sensation in dermatomes, and reflexes (patellar, Achilles).
Differential Diagnosis
The differential diagnosis for back pain is broad. Common causes include mechanical back pain (musculoskeletal strain), disc prolapse, spinal stenosis, spondylolisthesis, and facet joint arthropathy. Less common but serious causes include infection (discitis, osteomyelitis), malignancy (primary or metastatic), inflammatory arthropathies (ankylosing spondylitis), and abdominal aortic aneurysm.
| Condition | Key Features | Red Flags |
|---|---|---|
| Mechanical Back Pain | Gradual onset, activity-related, improves with rest | None specific, but consider if severe or persistent |
| Disc Prolapse | Sudden onset, radiating pain (sciatica), neurological deficits | Cauda equina symptoms, progressive neurological deficit |
| Spinal Stenosis | Neurogenic claudication (pain worse with walking, relieved by sitting/flexion) | Severe neurological deficit |
| Infection (e.g., Discitis) | Constant, severe pain, fever, elevated inflammatory markers | Fever, sepsis signs |
| Malignancy | History of cancer, unexplained weight loss, pain worse at night | Unexplained weight loss, history of cancer |
Management Strategies (UK Guidelines)
Management is guided by NICE (National Institute for Health and Care Excellence) guidelines. For non-specific low back pain without red flags, the focus is on conservative management.
The management of non-specific low back pain typically follows a stepped approach. Initial advice focuses on staying active and avoiding prolonged bed rest. Exercise therapy, including strengthening and stretching, is a cornerstone of treatment. Manual therapy (e.g., physiotherapy, chiropractic) may be considered for short-term relief. Pharmacological management includes simple analgesics (paracetamol, NSAIDs) and, if necessary, short courses of stronger analgesics or muscle relaxants. For persistent pain, psychological support and multidisciplinary approaches are important.
Text-based content
Library pages focus on text content
NICE guidelines strongly recommend advising patients to stay active and avoid bed rest for non-specific low back pain. Exercise is key!
Pharmacological Management
For acute low back pain, paracetamol or NSAIDs are first-line. If pain is severe, a short course of a stronger oral analgesic (e.g., codeine) or a muscle relaxant (e.g., diazepam) may be considered, but with caution due to side effects and potential for dependence. Topical NSAIDs can also be an option.
Referral and Investigations
Imaging (X-ray, MRI, CT) is generally not recommended for non-specific low back pain unless red flags are present or there is suspicion of specific pathology. Referral to specialist services (e.g., physiotherapy, pain clinic, orthopaedics, rheumatology) is indicated for persistent or severe symptoms, or when red flags are identified.
Imaging is indicated when red flags are present, suggesting serious pathology like infection, malignancy, or significant nerve root compression, or if symptoms are severe and persistent despite conservative management.
Specific Conditions and Management
Management varies for specific diagnoses. For example, cauda equina syndrome is a surgical emergency requiring immediate referral. Inflammatory conditions like ankylosing spondylitis require rheumatological input and disease-modifying drugs.
Loading diagram...
Learning Resources
The definitive UK guideline for the assessment and management of low back pain and sciatica, providing evidence-based recommendations.
A comprehensive overview of back pain, its causes, symptoms, and treatment options from the National Health Service.
An educational module covering the assessment and management of low back pain, suitable for healthcare professionals.
Clinical guidance and resources for GPs on managing back pain, often referencing NICE guidelines.
A detailed resource on low back pain, including assessment, differential diagnosis, and physiotherapy management.
Patient-friendly information on back pain, its causes, and self-management strategies.
A detailed medical overview of low back pain, including pathophysiology, diagnosis, and treatment, aimed at clinicians.
Information from the CSP on how physiotherapy can help manage back pain.
A comprehensive clinical decision support resource on evaluating acute low back pain, often used by physicians.
Resources and information on the management of low back pain from a pain medicine perspective.