Lower back pain is pain which occurs between the bottom of the rib cage and the buttock creases with or without pain in the upper legs .
Back pain is the largest single cause of lost working hours amongst both manual and sedentary workers; in the former, such as miners, dockers and nurses, it is an important cause of disability.
Although most people get back pain, and although there are a large number of possible causes, a precise diagnosis is made in only a few cases.
The recommended approach includes:
take a good history and examine the patient well
remember the rare, but deadly, causes of pain such as aortic aneurysm or myelomatosis
Lower back pain can be divided according to its duration:
acute (<6 weeks)
sub-acute (6 weeks-12 weeks)
chronic (>12 weeks)
Such a rigid categorization might not be useful in practice since symptoms in patients may wax and wane
In acute low back pain patients can be counselled that :
prognosis for relief of pain and returning to normal activities is favourable – most patients who are initially off work, return to work within 1 month
most of the patients who do not return to work within 1 month will return to work within 6 months
however note that residual symptoms and recurrences are common
Serious conditions whose signs and symptoms can cause low back pain are listed below.
Cauda equina syndrome. Red flags include:
Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine).
Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
Unexpected laxity of the anal sphincter.
Spinal fracture. Red flags include:
Sudden onset of severe central spinal pain which is relieved by lying down.
A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids.
Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
There may be point tenderness over a vertebral body.
Cancer. Red flags include:
The person being 50 years of age or more.
Gradual onset of symptoms.
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
Localised spinal tenderness.
No symptomatic improvement after four to six weeks of conservative low back pain therapy.
Unexplained weight loss.
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
The possibility that a person may die within the next few days or hours should be recognised and communicated clearly. Decisions should then be made and actions taken in accordance with the person’s needs and wishes. These should be regularly reviewed and decisions revised accordingly.
Sensitive communication should take place between healthcare professionals and the dying person, and those identified as important to them.
The dying person, and those identified as important to them, should be involved in decisions about treatment and care to the extent that the dying person wants.
The needs of families and others identified as important to the dying person should be actively explored, respected and met as far as possible.
An individual tailored plan of care should be agreed, coordinated and delivered with compassion.This includes support to eat and drink as long as they wish to do so, as well as symptom control and psychological, social and spiritual support to ensure their comfort and dignity.
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