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:

Muscular	-Acute onset lower back pain -Paraspinal muscles affected, not central
Lumbar spondylosis and facet joint syndrome (lumbar arthritis)	-Chronic episodic mechanical lower back pain -Backache related to standing/walking a lot/sitting in one place -Progressive stiffening
Lumbar disc prolapse	-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)
Discitis	-Fever and systemic upset -Risk factors, e.g. injecting drug user
Spinal fracture	-History of trauma -Sudden onset
Cauda equina syndrome	-Urinary incontinence/retention -Faecal incontinence/constipation -Saddle anaesthesia or paraesthesia  -Bilateral leg pain and weakness

Rheumatological:

Ankylosing spondylitis

-Morning stiffness >30 minutes  -Pain worse on rest

Others:

Other differentials

Myeloma bone lesions, Bony metastasis, Paget’s disease, Spondylolisthesis, Osteoporotic vertebral collapse, 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:

Rheumatoid arthritis	-Slowly progressive symmetrical polyarthropathy -Small joints (commonly of hand) -Deforming -Early morning stiffness
Gout	-First MTP joint most commonly affected -Isolated swollen, hot, painful joint -Hyperuricaemia risk factors, e.g. diuretics, alcohol excess (esp. beer), renal disease
Psoriatic arthritis	-Associated skin plaques and nail changes -Early morning stiffness -Many patterns of joint involvement
SLE	-Systemic illness with intermittent fevers -Photosensitive rash -Generalised myalgia and arthralgia -Other systemic symptoms (e.g. psychiatric, pleurisy, ulcers)
Enteropathic arthritis	-Symmetrical arthritis of lower limb joints and sacroiliac joints -Early morning stiffness -Symptoms/diagnosis of Crohn’s or UC

Orthopaedic:

Osteoarthritis	-Elderly -Worse on movement (rest helps) and at end of day, night pain common
Septic arthritis	-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

Now it’s your turn to shine! Here are some history stations…

1. Back pain
2. Joint pain
3. And more joint pain!
4. Time for a different joint
5. See more here…