Approach to Acute Back Pain

Differential diagnosis

• Neurological
  • Spinal cord compression
  • Spinal stenosis
  • Epidural haematoma
  • Spinal tumour
  • Guillain-Barre syndrome
• Infective
  • Discitis
  • Epidural abscess
  • Pyelonephritis
  • Acute pancreatitis
• Bone
  • Bony metastases
  • Osteoporotic fracture
    • Cushing’s syndrome
    • Menopause
    • Rheumatoid arthritis
    • Hypogonadotropic hypogonadism (e.g. secondary to pan-hypopituitarism)
    • Coeliac disease
    • Inflammatory bowel disease
    • Hyperparathyroidism
    • Renal bone disease
    • Hyperthyroidism
  • Traumatic fracture
  • Multiple myeloma
• Vascular
  • Aortic dissection
  • Spinal artery dissection
  • Ruptured abdominal aortic aneurysm
• Autoimmune
  • Ankylosing spondylitis
  • Psoriatic arthritis
• Mechanical back pain

History

• SOCRATES
• Any weakness?
• Any numbness?
• Any difficulty passing urine?
• Any difficulty with passing motion?
• Does the pain get better when you sit?
• Does it get worse when you walk?
• Any loss of weight / loss of appetite?
• Do you feel more tired than usual?
• Do you feel excessively thirsty? Passing a lot of urine?
• Any change in bowel habit / PR bleed?
• Any smoking history?
• Any breast lumps?
• Any pain on passing urine?
• Any blood in urine?
• Any difficulty in initiating urination? Terminal dribbling?
• Any fever?
• Any night sweats?
• Any recent admission to hospital?
• Any previous operations?
• Any previous fractures?
• From standing height?
• Any trauma?
• Any early morning stiffness?
• Does back pain get better with exertion?
• Any rashes?
• Have you ever had episodes of red, painful eyes?
• Any abdominal pain?
• Do you lift heavy loads?
• What is your job?

Examination

• Stand up and look at back
• Point tenderness along spine
• Schoeber’s test
• Range of movement
  • Flexion / extension
  • Rotation
• Gait
• Abdo:
  • Renal punch
  • AAA
• Straight leg raise
• Palpable bladder
• Power in bilateral lower limbs
• Plantars
• Psoriatic rash
• Psoriatic nail changes
• Ankylosing spondylitis:
  • Heart: aortic regurgitation
  • Eyes: anterior uveitis
  • Lungs: upper lobe fibrosis
  • Achilles tendinitis
  • Atlanto-axial subluxation
• Offer DRE