Back pain

Differential Diagnosis

• Disc prolapse

• Facet joint arthropathy/pain (spondylosis)

• Muscular tear/spasm

• Osteoporotic fracture

• Pathological fracture

• Spinal epidural abscess

• Vertebral osteomyelitis

• Septic discitis

• Pott’s disease (tuberculosis of the spine)

• Spondylolysis

• Spondylolisthesis

• Spinal stenosis

• Paget’s disease of bone

• Multiple myeloma

• Abdominal aortic aneurysm (AAA)

• Herpes zoster (especially when pain is dermatomal)

• Cauda equina syndrome

• Ankylosing spondylitis

• Nephrolithiasis

• Hyperparathyroidism

• Mechanical back pain (particularly non-specific low back pain)

Red Flags (Indications for Early Imaging)

• Age >50 years

• Unexplained fever, night sweats

• Unintentional weight loss

• Saddle anaesthesia

• Urinary retention or overflow incontinence

• Bladder or faecal incontinence

• Intravenous drug use (IVDU)

• Immunocompromised state (e.g. long-term steroid use)

• Night and rest pain

• Severe or progressive lower limb motor symptoms

• Bilateral leg symptoms

• Pain persisting >4–6 weeks despite conservative treatment

• Known malignancy history

History

• Explore onset, duration, character, and radiation of pain

• Enquire about systemic symptoms (fever, weight loss), neurological deficits (numbness, weakness), and bladder or bowel incontinence

• Assess lifestyle factors, psychosocial issues, and any occupational or sports-related risk factors

• Document history of trauma, osteoporosis, malignancy, or risk factors for infection

Examination

• Neurological assessment of the lower limbs (motor, sensory, and reflexes)

• Saddle anaesthesia testing and anal sphincter tone assessment where indicated

• Palpate the spine for tenderness and check for vertebral point tenderness

• Observe spinal range of motion (ROM) and assess gait

• Look for any postural abnormalities or signs of deformity (e.g. scoliosis)

Investigations

Imaging

• Plain X-ray: useful to identify fractures, significant degenerative changes, spondylolisthesis

• MRI: indicated for neurological deficits, suspected malignancy, infection, or unresolved red flags

• CT: may help delineate bony detail if MRI is contraindicated

Laboratory Tests

• FBE, ESR, CRP to screen for infection/inflammation

• PSA (for prostate cancer), calcium/ALP (for Paget’s disease) when clinically indicated

Management

General Back Pain

• Encourage continued activity and discourage prolonged bed rest

• Paracetamol 1 g QID and/or NSAIDs (e.g. ibuprofen 400 mg TDS) as needed

• Consider a short course of muscle relaxants if severe spasm is present

• Early referral to physiotherapy for core strengthening, stretching, and manual therapy as appropriate

• Assess and address psychosocial factors (yellow flags) that may delay recovery (e.g. fear avoidance, depression, or workplace stress)

• Reassure most cases improve within 4–6 weeks with conservative measures

• Advise follow-up in 3–6 days for re-assessment, especially if symptoms worsen

Back Pain with Bone Metastasis

• Analgesia ladder: paracetamol, NSAIDs, opioids (e.g. oxycodone 5 mg QID), and corticosteroids (e.g. dexamethasone 4–8 mg)

• Consider adjuvants such as bisphosphonates or denosumab and referral for radiotherapy

• Multidisciplinary management (palliative care, oncology, physiotherapy)

Additional Considerations

• Avoid imaging in the first 4–6 weeks of non-specific back pain unless red flags are present

• Screen for psychological distress, as it can contribute to chronicity

• In older patients, assess for osteoporosis and fracture risk

• Chronic or recurrent back pain may warrant investigation for inflammatory causes (e.g. ankylosing spondylitis)

Complications

• Chronic pain and associated functional limitations

• Neurological deficits if nerve roots or spinal cord are involved (e.g. cauda equina syndrome)

• Deconditioning due to fear avoidance of movement

• Psychological impact, including depression and anxiety

Prognosis

• Most acute non-specific back pain resolves within a few weeks

• Persistent or severe pain requires thorough investigation to exclude serious pathology

• Early intervention addressing both physical and psychosocial factors improves outcomes