Table of Contents
Lower back pain
Exploring symptom
- Pain
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating/relieving factors
- Severity
- Associations
- Sciatica, stiffness/deformity, incontinence, neurological symptoms
- Red flags
- Cauda equina: urinary incontinence/retention, faecal incontinence/constipation, bilateral leg pain, severe/progressive neurological deficit, saddle anaesthesia, sexual dysfunction
- Infection or cancer: age <20 or >55 years at onset, cancer Hx, night pain, weight loss, fever, night sweats, injecting drugs, immunosuppression
- Fracture: trauma, severe central spinal pain
- Spondyloarthropathy: early morning stiffness, worse with rest
Relevant system reviews
- General
- Fever, night sweats, weight loss
- Neuro (lower limbs)
- Motor: weakness/wasting, incontinence
- Sensory: pain, numbness, tingling
Differential diagnoses and clues
Orthopaedic
- Acute onset lower back pain
- Paraspinal muscles affected, not central
Includes lumbar facet joint syndrome (lumbar arthritis)
- Chronic episodic mechanical lower back pain
- Backache related to standing/walking a lot/sitting in one place
- Progressive stiffening
- Acute onset while lifting / bending / sneezing / coughing
- Severe pain
- Sciatica, leg pain often worse than back pain
- Neurological symptoms, e.g. weakness, numbness (usually L4/L5/S1 distribution)
- Fever and systemic upset
- Risk factors, e.g. injecting drug user
- History of trauma
- Sudden onset
- Urinary incontinence/retention
- Faecal incontinence/constipation
- Saddle anaesthesia or paraesthesia
- Bilateral leg pain and weakness
Rheumatological
- Morning stiffness >30 minutes
- Pain worse on rest
Others
- Bony
- Myeloma bone lesions
- Bony metastasis
- Paget’s disease
- Spondylolisthesis
- Osteoporotic vertebral collapse
- Abdominal
- Pyelonephritis
- PID
- Pancreatitis
- AAA
Joint pain / stiffness / swelling
Exploring symptom
- Pain
- Site(s)
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating/relieving factors
- Severity
- Stiffness/swelling
- Worse in morning?, how long for (>30 mins = inflammatory; <30 mins = osteoarthritis)
- Better or worse after exercise
- Sleep disturbance
- Loss of function
Relevant system reviews
- General
- Fever, rashes, weight loss
- Rheumatological
- Joints: pain, stiffness, swelling
- Work down body: skin (rashes, ulcers, Raynaud’s), hair loss, eyes (redness, dryness), mouth (dryness), chest (breathlessness, SOB), GI (IBD symptoms), genitourinary (discharge
Differential diagnoses and clues
Rheumatological
- Slowly progressive symmetrical polyarthropathy
- Small joints (commonly of hand)
- Deforming
- Early morning stiffness
- First MTP joint most commonly affected
- Isolated swollen, hot, painful joint
- Hyperuricaemia risk factors, e.g. diuretics, alcohol excess (esp. beer), renal disease
- Associated skin plaques and nail changes
- Early morning stiffness
- Many patterns of joint involvement
- Systemic illness with intermittent fevers
- Photosensitive rash
- Generalised myalgia and arthralgia
- Other systemic symptoms (e.g. psychiatric, pleurisy, ulcers)
- Symmetrical arthritis of lower limb joints and sacroiliac joints
- Early morning stiffness
- Symptoms/diagnosis of Crohn’s or UC
Orthopaedic
- Elderly
- Worse on movement (rest helps) and at end of day, night pain common
- Isolated hot, red, swollen joint
- Agonizingly painful
- Systemically unwell with fever
Others
- Single joint
- Traumatic (dislocation/fracture/ligament injury)
- Haemophilia (haemarthrosis)
- Pseudogout
- Joint specific problems (e.g. knee – chondromalacia patellae, Osgood-Schlatter’s disease, patellar tendonitis; hip – avascular necrosis)
- Adhesive capsulitis
- Transient synovitis
- Bursitis
- Reiter’s syndrome
- Multiple joints
- Viral polyarthritis (e.g. flu, HIV, hepatitis, rubella)
- Other connective tissue disorders (e.g. systemic sclerosis, polymyositis, polyarteritis nodosa)
- Other spondyloarthropathies (e.g. ankylosing spondylitis, Reiter’s syndrome, Behçet’s disease, juvenile chronic arthritis, rheumatic fever)
Try some viva questions
Please list some differentials for lower back pain
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What are the RED FLAGS of back pain?
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What treatment options are there for chronic nonspecific back pain?
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Which investigations may be used to help differentiate the causes of back pain?
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Name the three main causes of spinal disc pathology
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