Back Pain and its presentation, DDs, red Flags, investigations, managment and Advices.pptx

Classification of back pain
Identify common etiologies of Acute/chronic back pain
Identifying Red flags
Identify treatment possibilities
Advices for the patient
Case discussion
Causes of Acute Back Pain:
Muscle or Ligament Strain: Overstretching, lifting heavy objects, or sudden movements can strain muscles or ligaments in the back.
Bulging or Ruptured Discs: Discs act as cushions between vertebrae, and if one bulges or ruptures, it can compress nerves, causing pain.
Spinal Fracture: Trauma from falls, accidents, or sports can cause vertebral fractures, leading to sharp pain.
Poor Posture: Slouching or sitting improperly for long periods can strain the muscles and ligaments in the back.
Sports Injuries: High-impact sports or improper training techniques can cause sprains, strains, or tears in back muscles.
Sciatica: Compression of the sciatic nerve (from herniated discs or other conditions) leads to shooting pain down the leg, often starting from the lower back.
Sudden Movements or Twisting: Jerky or awkward movements, like twisting too quickly, can cause immediate strain.
Chronic:
Degenerative Disc Disease: With age, spinal discs lose their cushioning ability, leading to chronic pain from nerve compression or bone-on-bone contact.
BPH: In Male, BPH can cause back pain along with urinary symtoms
Spinal Stenosis: Narrowing of the spinal canal, often due to aging, puts pressure on the spinal cord and nerves, causing persistent back pain.
Arthritis: The inflammation and degeneration of joints in the spine can lead to chronic pain and stiffness.
Herniated Disc: A disc that remains herniated for a long time can continuously press on nerves, causing ongoing discomfort.
Fibromyalgia: A chronic pain condition that can affect the back, among other areas, often causing muscle stiffness and tenderness.
Osteoporosis: Thinning bones from osteoporosis can lead to fractures, even with mild trauma, resulting in persistent back pain.
Chronic Infections or Tumors: Although rare, chronic infections (e.g., tuberculosis of the spine) or spinal tumors can cause prolonged back pain.
Red Flags: Unexplained weight loss
Fever or chills
History of cancer
Night pain or pain that worsens at rest
Trauma or recent injury
Prolonged use of steroids
Cauda Equina syndrome: Bowel or bladder dysfunction, Saddle anesthesia (numbness in the groin area)
Neurological symptoms (e.g., numbness, weakness, or tingling)
History of osteoporosis
Severe or progressive motor weakness
Differential Diagnoses (DDx):
Lumbar Muscle Strain: Likely due to lifting a heavy object; sharp pain and localized tenderness.
Herniated Lumbar Disc: Possible due to radiation into the buttock and leg; could compress the sciatic nerve.
Lumbar Facet Joint Syndrome: Pain exacerbated by movement, especially bending and twisting.
Sciatica: The radiation of pain down the right leg suggests potential involvement of the sciatic nerve.
Degenerative Disc Disease: Could be considered due to age and mechanical stress on the sp

1. Back Pain Dr Zeshan Zaman Khan MBBS, MRCGP Clarence Town Healthcare

2. AIMS: Classification of back pain Identify common etiologies of A cute/chronic back pain Identifying Red flags Identify treatment possibilities Advices for the patient Case discussion

3. Classification Acute <4 weeks Sub acute 4-12 weeks Chronic > 3 months

4. Causes of Acute Back Pain: Muscle or Ligament Strain : Overstretching, lifting heavy objects, or sudden movements can strain muscles or ligaments in the back. Bulging or Ruptured Discs : Discs act as cushions between vertebrae, and if one bulges or ruptures, it can compress nerves, causing pain. Spinal Fracture : Trauma from falls, accidents, or sports can cause vertebral fractures, leading to sharp pain. Poor Posture : Slouching or sitting improperly for long periods can strain the muscles and ligaments in the back. Sports Injuries : High-impact sports or improper training techniques can cause sprains, strains, or tears in back muscles. Sciatica : Compression of the sciatic nerve (from herniated discs or other conditions) leads to shooting pain down the leg, often starting from the lower back. Sudden Movements or Twisting : Jerky or awkward movements, like twisting too quickly, can cause immediate strain .

5. Causes of Chronic back pain: Degenerative Disc Disease : With age, spinal discs lose their cushioning ability, leading to chronic pain from nerve compression or bone-on-bone contact . BPH: In Male, BPH can cause back pain along with urinary symtoms Spinal Stenosis : Narrowing of the spinal canal, often due to aging, puts pressure on the spinal cord and nerves, causing persistent back pain. Arthritis: The inflammation and degeneration of joints in the spine can lead to chronic pain and stiffness. Herniated Disc : A disc that remains herniated for a long time can continuously press on nerves, causing ongoing discomfort. Fibromyalgia : A chronic pain condition that can affect the back, among other areas, often causing muscle stiffness and tenderness. Osteoporosis : Thinning bones from osteoporosis can lead to fractures, even with mild trauma, resulting in persistent back pain. Chronic Infections or Tumors : Although rare, chronic infections (e.g., tuberculosis of the spine) or spinal tumors can cause prolonged back pain.

6. Red Flags for Back Pain: Unexplained weight loss Fever or chills History of cancer Night pain or pain that worsens at rest Trauma or recent injury Prolonged use of steroids Cauda Equina syndrome : Bowel or bladder dysfunction, Saddle anesthesia (numbness in the groin area ) Neurological symptoms (e.g., numbness, weakness, or tingling) History of osteoporosis Severe or progressive motor weakness

7. Scenario: A 45-Year-Old Male with Acute Lower Back Pain

8. Exploring the Pain: Site : The patient reports pain primarily in the lower back , dull and aching at rest. Onset : The pain started 2 days ago after lifting a heavy box at work. The onset was sudden , but the pain has been worsening. Radiation : The pain radiates down the right leg but does not extend below the knee. Associated symptoms : No numbness, tingling, or weakness in the legs. The patient denies bowel or bladder dysfunction. Timing : The pain is constant , with sharp increases when standing or walking for long periods. It feels worse in the evening and after sitting for prolonged periods. Exacerbating and relieving factors : The pain worsens with bending, lifting, and twisting and improves with rest, lying flat, and over-the-counter analgesics . Severity : On a scale of 1 to 10, the pain is rated as a 7/10 at its worst.

9. Differential Diagnoses: Lumbar Muscle Strain : Likely due to lifting a heavy object; sharp pain and localized tenderness. Herniated Lumbar Disc : Possible due to radiation into the buttock and leg; could compress the sciatic nerve. Sciatica : The radiation of pain down the right leg suggests potential involvement of the sciatic nerve. Degenerative Disc Disease : Could be considered due to age and mechanical stress on the spine. Spinal Stenosis : Less likely, but the age and nerve involvement could point towards narrowing of the spinal canal. Vertebral Compression Fracture : Unlikely due to the absence of trauma, but could still be considered in cases of osteoporosis.

10. Asking for Red Flags: FLAWS: Fever, Loss of appetite, unexplained weight loss, Night sweats Trauma : Positive Neurological symptoms : "Have you had any numbness, tingling, or weakness in your legs?" Bowel or bladder dysfunction : "Have you had any trouble controlling your bowel or bladder?" Saddle anesthesia : "Have you noticed any numbness in your groin or around the buttocks?" Severe or progressive motor weakness : "Are you experiencing weakness that's getting worse in your legs or back?"

11. Past History of Similar Pain: The patient reports experiencing mild lower back pain a few times in the past year after physical activity but never as severe as this Previous episodes resolved on their own after a few days of rest and occasional use of ibuprofen . Past Medical History: Hypertension: Controlled with medication (losartan). No history of diabetes, heart disease, or other chronic conditions. No history of spinal surgeries or disc issues. No known allergies

12. Social History Diet : Balanced, mostly home-cooked meals, but with occasional fast food. Not on any special diet. Exercise : Occasional exercise; walks 2-3 times a week, but does not engage in any regular strength training. Smoking : Former smoker , quit 5 years ago after smoking for 15 years (1 pack/day). Alcohol : Drinks alcohol occasionally, about 2-3 drinks per week.

13. MAFTOSA Medical History : HTN+ Allergies : N o known Allergies . Family history: No significant family history of back problems Travel history : N ot traveled recently to areas where infections or conditions that could affect the spine are prevalent (e.g., tuberculosis). Occupations : Works in a clothes f actory. Involved in lifting heavy cartons Smoking : The patient is a former smoker , having quit 5 years ago after smoking for 15 years at a rate of 1 pack per day. Anything else : Nill

14. Ideas, Concerns, and Expectations: Ideas : The patient believes the pain is from a muscle strain due to lifting and expects it to improve with rest. Concerns : He is worried about the radiation of pain into the leg and whether this could indicate a serious problem, such as a slipped disc . Expectations : He hopes for reassurance and effective pain relief and would like to know how to prevent future episodes.

15. Observation and Clinical Examination: Observation : The patient walks with a slight limp, favoring the right side. Clinical Examination : Inspection : No visible deformity or swelling in the lower back. Normal spinal alignment. Palpation : Tenderness over the right lumbar paraspinal muscles . No significant tenderness over the vertebrae. Range of Motion (ROM) : Limited and painful forward flexion and lateral bending to the right. Straight Leg Raise (SLR) : Positive on the right side at 40 degrees, eliciting pain in the lower back and radiating into the buttock. Neurological Exam : Reflexes, muscle strength, and sensation in the lower limbs are normal. No signs of weakness or numbness. Gait : Slightly altered but stable; no significant abnormalities in coordination.

16. Investigations: Routine Investigations : Blood Tests: Complete blood count (CBC): To rule out infection. Inflammatory markers (CRP, ESR): To check for inflammation or infection. Basic metabolic panel: To check kidney function (important for analgesic management). Specific Investigations : X-ray of Lumbar Spine : To check for fractures, degenerative changes, or spinal alignment issues. MRI of Lumbar Spine (if the pain persists or neurological symptoms develop): To rule out disc herniation or nerve compression. Nerve Conduction Studies (if sciatica is suspected): To assess nerve function if symptoms of sciatica worsen.

17. Diagnosis: Based on the clinical picture, the likely diagnosis is acute lumbar muscle strain with a possible component of sciatica (right-sided) due to irritation or mild compression of the sciatic nerve. Herniated disc cannot be ruled out and will require further investigation (MRI) if symptoms do not improve with conservative treatment.

18. Treatment: Medications : Pain Relief : NSAIDs (e.g., ibuprofen) for pain and inflammation, as long as there are no contraindications. Muscle relaxants (e.g., cyclobenzaprine) for relief of muscle spasms. If pain is severe, consider a short course of opioids for acute pain management, but limit use to prevent dependency. Topical Analgesics (e.g., capsaicin cream or lidocaine patches) may also provide localized relief. 2. Physical Therapy : Referral to physical therapy for exercises focused on strengthening the core muscles and improving posture. Stretching and lumbar stabilization exercises to promote healing and prevent recurrence.

19. Continued: 3. Heat/Ice Therapy : Apply ice to the area for 20 minutes at a time during the first 48 hours to reduce inflammation, then switch to heat to relax muscles. 4 . Ergonomics and Posture : Advice on maintaining proper posture, particularly when sitting for extended periods or lifting objects. Consider ergonomic adjustments at work (e.g., proper chair, back support). 5 . Follow-up : Schedule a follow-up appointment in 1-2 weeks to assess improvement. If there is no significant improvement, or if symptoms worsen, consider an MRI for further evaluation.

20. Lifestyle Advice: Rest and Activity : Relative rest for 1-2 days, but avoid prolonged bed rest as it can delay recovery. Gradually resume light activities like walking, avoiding heavy lifting and twisting movements . Diet : Maintain a balanced diet with adequate calcium and vitamin D to support bone health. Exercise : Engage in regular, low-impact exercises like swimming or walking to strengthen the back and core muscles. Smoking cessation : Continued abstinence from smoking is important for overall health and reducing the risk of degenerative spinal conditions. Alcohol : Continue moderate alcohol consumption within safe limits.

21. THANK YOU