Back pain

• What is back pain?
• Statistics on back pain
• Risk factors for back pain
• Progression of back pain
• Symptoms of back pain
• Clinical examination of back pain
• How is back pain diagnosed?
• Prognosis of back pain
• Treatment of back pain
• References

What is back pain?

Back pain, particularly lower back pain, is a very common reason for patients visiting their local doctor. Although the underlying pathology is usually not serious, it is an important cause of pain in the community and has considerable impact on the economy due to time taken off work.
Back pain is often secondary to back trauma and usually resolves after a short period of time. Occasionally it may indicate a more serious underlying condition.

Statistics on back pain

Back pain is an extremely common condition. Up to 80% of individuals will experience back pain at some time during their lives.
The vast majority of patients with back pain will recover within 6 or so weeks, while a small number will go on to develop long-term pain, other symptoms or problems with function.
Back pain is one of the leading reasons for a patient to visit a doctor but the underlying cause of the pain is not always obvious.

Men

Research has shown that approximately 7/10 men will experience back pain at some time in their lives. For the majority of men, there will be no apparent cause or injury and only 2/10 men can identify a particular injury, event or accident to be the cause of the pain. Physicians themselves may have difficulty eliciting the cause of the back pain also.

Women

Back pain is slightly more common in women than men. A survey of the point prevalence of back pain in workers showed that approximately half of women sufferred recurrent back pain. However, women were less likely to take time off work or to speak to their employer about the pain.
Women can suffer back pain from menstruation, pregnancy, arthritis and osteoporosis (thinning of the bones). Studies have shown that around 80% of women suffer back pain during pregnancy. If women experience back pain during mentruation at a young age, they may become used to back pain and not immediately seek medical advice.

Children

Back pain in children is considered more serious than that in adults. Pain in young children (particularly those under 4 years of age) is more likely to result from a serious underlying disorder.
All back pain in children should be considered as serious. If your child has back pain for several days or pain that worsens, medical advice should be sought. This allows early identification of the problem to avoid progression and long-term complications.

Risk factors for back pain

Features that suggest an increased likelihood of back pain due to a serious cause include:

• Increased age;
• History of violent trauma or injuries;
• History of cancer;
• History of drug use;
• Weight loss;
• Fever of unknown cause;
• Nervous system problems (leg weakness, loss of control of bladder);
• Constant unrelieved pain;
• Use of corticosteroid and blood thinning medications.

Children

Back pain in children should be considered serious. In young children the cause is often sinister such as infection or tumours. Older children may suffer from inflammation, trauma or psychosomatic causes in addition to those above.
Adolescents can quite commonly suffer from Scheuermann’s syndrome. In this condition damage to the bones causes the spine to become increasingly rounded (like a hunch back) which can lead to significant deformity and long-term complications.
Stress fractures, slipped vertebrae, tumours and infections are other serious causes to consider but the most common cause is musculoskeletal pain.

Progression of back pain

It is often extremely difficult to identify the cause of back pain in the general practice setting. Only a small number of patients will have an underlying disease, and fewer still have a life-threatening condition. Serious conditions include infection, cancer, rheumatologic diseases (rheumatoid arthritis, ankylosing spondylitis) and when there is involvement of the nervous system.
The most common causes of lower back pain are mechanical. Examples include spinal joint dysfunction and disc prolapse (commonly referred to as a ‘slipped disc’), muscular strains and arthritis in the spine (which increases as people age).
Serious conditions include cancer (usually from another source such as the prostate or lung), serious infections and compression of the spinal cord.
Other causes include inflammatory arthritis (e.g. ankylosis spondylitis, reactive arthritis, and psoriatic arthritis), and fractures due to osteoporosis. Back pain may also be ‘referred’ from another location.
In degenerative conditions, spinal disease and sacroilliac disease the onset is typically gradual. In contrast, back pain secondary to injury is often sudden in onset and may occur in a previously well individual. Crushing, lifting and twisting forces can lead to bone, ligament and muscular damage respectively.

How is back pain diagnosed?

Investigations are selected based on the patient’s symptoms and the physical findings on examination. A patient who is generally well, with back pain that has only been present for a short time and is not too severe probably doesn’t require further testing, as this is likely to recover by itself. Patients who have ongoing relieved pain, systemic symptoms such as fever, or neurological signs (weakness, sensory changes) do need further tests as their condition is likely to be more serious.
Tests commonly done for back pain include blood tests and X-rays of the spine. Sometimes CT or MRI scans are also needed as they give a more accurate picture of the structure of the spine. Bone scans are sometimes useful if infection, cancer or fractures are suspected.

Prognosis of back pain

The majority of patients who experience back pain due to non serious causes will recover within 6 weeks. However, repeated episodes of back pain are common, and occur in 40-70% of patients. A small percentage of patients will go on to develop chronic back pain.

Treatment of back pain

Treatment of back pain may encompass various therapies including; rest, medications to relieve pain and muscle spasm, heat application, massage, exercises targetting back muscles, weight loss, smoking cessation, surgery and rehabilitation. Particular treatments used are highly dependent on whether underlying causes are identified
Most back pain is due to mechanical causes, which while distressing is usually not serious and will not cause long term damage. In these cases, patients are reassured that their pain should recover or improve over the next few weeks.
Symptoms can be relieved with physiotherapy and appropriate pain medications.
A small number of patients may need to have surgery. Surgery carries risks which need to be considered, but for the right patients it may provide dramatic relief of symptoms and return to normal activities.

References

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2. Solomon L, Warwick D, Apley AG, Nayagam S. Apley’s System of Orthopaedics and Fractures (8th edition). London: Edward Arnold Publishers; 2001.
3. Bogduk N. Management of chronic low back pain. Med J Aust. 2004;180(2):79-83. [Abstract | Full text]
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8. Murtagh J. Murtagh’s General Practice (3rd edition). North Ryde, NSW: McGraw Hill Australia; 2003.
9. Patel AT, Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician. 2000;61(6):1779-90. [Full text]
10. Shirley. The prevalence of back pain in men. Men’s health: Mind, body and heart. 2000.