Musculoskeletal symptoms straddle several specialities: orthopaedics, rheumatology and general medicine. To unravel the problem, you need an understanding of anatomy and normal joint function, as well as information about your patient’s medical history, lifestyle, daily activities – and their expectations of treatment.
Back Pain
Some 60–80% of us will get back pain, so it’s a common symptom. Every year around 2.6 million people in the UK see their GP for back pain. It’s also the single biggest cause of time off work.
Most back pain is ‘mechanical’ – linked with posture or the way the back is used – rather than with fracture, inflammation, neoplasia or other pathology. Attacks are often self-limiting, although around 20% develop long-term pain or disability.
The challenge is to spot the 1% who have a serious cause and to treat them promptly.
History
Onset of new back pain before the age of 20 or after 55 years – more likely to be malignancy (primary or secondary).
Where is the pain?
Thoracic pain is usually more serious. It may be a disc, TB, osteoporosis, osteomalacia or malignancy.
Radiation of pain to the knee is common with mechanical pain, but involvement of the foot suggests nerve root irritation, for instance from a herniated disc.
Weight loss or other systemic symptoms – think TB or malignancy.
Morning stiffness – suggests an inflammatory cause like ankylosing spondylitis.
Severe night pain – linked with malignancy.
Pain on walking a certain distance – may be neurogenic claudication from spinal stenosis.
Loss of bladder or bowel control – important symptoms of cauda equina syndrome.
Saddle anaesthesia (ask about numbness of the buttocks or the area around the back passage) – also a cauda equina symptom.
- Ask about occupation. It may involve heavy lifting, prolonged driving or work at a visual display unit (VDU) at the wrong height. Workplace factors may also reveal a desire for compensation.
- Family history is important with ankylosing spondylitis and TB.
- Ask about medication (e.g. steroids). You may also be surprised how many patients see their doctor about back pain before even trying paracetamol.
- Cigarette smoking is a risk factor because it affects blood flow to the spine.
- Finally ask ‘How are things generally?’ Depression can present as back pain.
Examination
Physical examination is informative, and reassures you and your patient.
- If your patient sits happily on the chair with legs crossed, it’s unlikely to be severe.
- Look for deformity or asymmetry.
- Check for tenderness of the spine.
- Assess spinal movements.
- Test straight leg raising. Pain at less than 80 degrees of hip flexion suggests nerve root irritation.
- Lower limb reflexes are usually normal, but may be reduced with disc prolapse.
- Test muscle power in the legs. It’s quicker and more informative than testing sensation, but check sensation in the perianal area for cauda equina.
- With first onset of back pain over 55 years, examine the breasts or perform a digital rectal examination (DRE) to assess the prostate. These carcinomas commonly spread to bone.
Investigations
FBC, ESR, CRP for inflammatory back pain, TB or malignancy. Protein electrophoresis for myeloma. Calcium and vitamin D levels if you suspect osteomalacia.
Patients often want the reassurance of an X-ray but imaging is unlikely to help unless you suspect TB, malignancy, ankylosing spondylitis or fracture (e.g. osteoporotic). You can explain that X-rays only show bones, not muscles or ligaments, the usual cause of back pain. Spinal X-rays also deliver around 50 times the amount of radiation given by a chest X-ray. MRI scans, where available, are far more helpful than X-rays, but even MRI has its limitations.
Management
- Rest for up to 24 hours helps acute back pain, but longer can weaken muscles and worsen the problem.
- Suggest heating pad or hot water bottle.
- Prescribe analgesics such as paracetamol (with or without codeine or dihydrocodeine) or ibuprofen.
- Address lifestyle and work factors. Advise a good bending and lifting technique, using the knees. PC users should adjust their workstation and take frequent breaks. Long-distance drivers also need breaks.
- Consider time off work.
- Advise simple exercises and swimming. Physiotherapy is very useful, especially for recurrent pain.
- Treat nerve root irritation the same way unless severe or worsening, in which case refer. Always refer suspected cauda equina syndrome urgently to orthopaedics or neurosurgery.
Cauda Equina Syndrome
The cause is usually a central disc protrusion at L4–5, but any space-occupying lesion below L2 can produce these symptoms:
Urinary and faecal incontinence
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