Low Back pain-(not an unusual

cause)
Adapted from source
 Presenting complaint

• 14:30pm, day 5
• 39yo male with 5/7 history of abdominal pain
 DAY 1 & 2
History of presenting complaint

• MVA 24/08 – stable compression # L1

• Presented to Hospital on day 1 c/o back ache
• Prescribed panadeine forte, consumed entire
pack overnight (20 tabs)
– intent was analgesia
• Became constipated
• Presented again on day 2 with diffuse abdo
pain & constipation
 DAY 3
History of presenting complaint

• Hosp administered an enema to re-open

bowels
• Transferred to nearby hospital for
management of OD & continued back ache
• day 3 (RMO)
– c/o increasing left lower abdominal pain
– bowel movement  no relief
– emesis x 4 since day 2
– Ex: tenderness, guarding, rebound…
 DAY 3
History of presenting complaint

• Imp: ? acute abdomen

– CXR, abdo x-ray (supine & erect) – NAD
• Rx: metronidazole/ampicillin/gent.
• Clear fluids
• Nursing: pt. irritable & easily angered
• Ψ PHO: not suicidal
 DAY 3
History of presenting complaint

• Medical SMO
– Hx: LLQ abdominal pain
– Ex:
• abdo slightly distended, not entirely soft, tender esp.
LLQ and epigastrium, Murphy’s -ive
– Ix: T 38, CRP 313mg/L, WCC 15.6x109/L
– Imp: severe intra-abdominal inflammation
– Plan:
• lipase, cont. antibiotics, CT abdomen, close obs
 DDx

• Pancreatitis
• Diverticulitis
• ???
 DAY 4
History of presenting complaint

day 4
• headache, abdo, back pain
• T 386, HR 101
• surgical PHO:
– Imp: probable diverticulitis
• patient:
– threatening to harm others, abusive
– QPS contacted to escort pt from hospital
– collateral history – long hx drug abuse
 DAY 4
History of presenting complaint

• blood cultures +ive for S. aureus

• 20:55pm
– patient contacted to return to hospital as cultures
+ CT indicate early left psoas abscess
 Back to day 5…

• patient presents to HBH ED

 DAY 5
Past medical history

• NKA
• current Rx
– tramadol, clomipramine, modafanil
• prev. bowel resection
• hx of:
– narcolepsy/cataplexy
– MVA 3/12 ago
• imm. UTD
• social hx – drug abuse, EtOH, cigs
 DAY 5
Examination

• T 371, HR 106, RR 18, BP 128/75

• right lower back tender to palpation
• abdominal guarding
• Plan:
– FBC, CRP, coagulation profile, Hep. C serology, LFT
– surgical consult
 DAY 5
Management

• surgical PHO:
– abdo distended
– max. tenderness LIF with rebound, voluntary
guarding
– pain on left hip flexion
– Plan:
• echo, bloods, CT, USS abdo
• IV fluids and antibiotics
• analgesia
Acute Low Back Pain

a diagnostic conundrum
 Epidemiology

•2nd most common cause of

msk disability after arthritis
•M=F
•60-80% will suffer LBP Incidence of LBP in HBH ED

34
35 31
during lifetime 30
29
27
30

22 23
25
•accounts for 40% of all Nr. Of Cases
20
19

15
work injuries 10 5
5

•220 cases in HBH ED 0

Mar Apr May Jun Jul Aug Sep Oct Nov
Month
since March 1st
 Risk factors

• smoking
• obesity
• older age
• work – sedentary, strenuous (phys, Ψ)
• low educational attainment
• job dissatisfaction
• Ψ – anxiety, depression, somatisation
 Clinical evaluation - history

1. Any evidence of systemic disease?

2. Any evidence of neurological compromise?
3. Any social or psychological distress that may
contribute to chronic, disabling pain?
– psychosocial Hx can assist estimating prognosis
& planning therapy
– screen for depression
 Clinical evaluation - history

•temporal pattern?
 Clinical evaluation – red flags 
•age >50 years
•history of cancer
•T >378 , ESR/CRP
•systemically unwell
•significant trauma
•movement in all directions
painful
•drug or alcohol abuse
•weight loss
•neurological deficit esp. weak
legs
•localised bony tenderness
•progressive, non-mechanical
pain
•use of steroids
•use of anticoagulants
•possible cauda-equina
–saddle anaesthesia
–recent onset bladder
dysfunction
–severe or progressive
neurological deficit
•night pain
 Clinical evaluation – yellow flags 

• Psychosocial risk factors

– Attitudes and beliefs about back pain
– Behaviours – avoidance, Rx abuse
– Compensation issues (e.g. WorkCover)
– Diagnosis and treatment
– Emotions
– Family
– Going back to work
 Clinical evaluation - examination

•Inspect back & posture

•Palpate spine
•Range of motion
•SLR, slump test (if leg Sxs
present)
–positive if pain is reproduced
–if +ive ~ disc disruption.
–if +ive, approach manual therapy
with caution
–if –ive, indicates lack of serious
disc pathology.
 Clinical evaluation - examination

• Neurological ex. of L5 & S1 roots (if leg Sxs

present)

• Evaluate for malignancy (breast, prostate, LN

exam)
Differential diagnosis – causes of LBP
 Differential diagnosis – probability diagnosis

• vertebral dysfunction
• musculo-ligamentous strain
• spondylosis (degenerative OA)
 Differential diagnosis – not to miss…

• CVS – ruptured AA, retroperitoneal

haemorrhage
• neoplasia – MM, mets (lung, Br, Pr)
• infections – OM, epidural abscess, discitis, TB,
pelvic abscess/PID
• cauda equina compression
 Differential diagnosis – not to miss…

• CVS – ruptured AA, retroperitoneal

haemorrhage
• neoplasia – MM, mets (lung, Br, Pr)
• infections – OM, epidural abscess, discitis, TB,
pelvic abscess/PID
• cauda equina compression
 Differential diagnosis – pitfalls

• spondyloarthropathies – AS, Reiter’s, psoriatic

arthritis, IBD
• SI dysfunction
• spondylolisthesis
• claudication – neurogenic, vascular
• prostatitis
• endometriosis
 Differential diagnosis – masquerades

• depression
• spinal dysfunction
• UTI
 Differential diagnosis – hidden agendas

• lifestyle
• stress
• work problems
• malingering
 Investigations

• screening tests
– x-ray, dipstick, ESR/CRP, ALP, PSA
• specific disorder tests
– e.g. HLA-B27, blood cultures, bone scan
• imaging
– CT, MRI: caution asymptomatic ‘abnormalities’
– discography
– myelography or radiculography
 Management - non-surgical

• EPASS
– Educate
• Ψsocial impacts, compliance
– Physical measures
• physio, wt. loss, hydrotherapy, creams, gels
– Analgesia
• Panadol Osteo, PRN Mobic, injections
– Steroids
– Splints
 Management - surgical

• 4 As
– An osteotomy
– Arthroplasty
– Arthrodesis
– Amputation – not sure about this one…
 Psoas abscess

• arise from haematogenous seeding or

contiguous spread from:
– intraabdominal source
– nearby bony structures e.g. vertebra
• S. aureus for haem/bony source
• enteric flora common if abdo source
• features:
– fever, lower abdo or back pain, or pain referred to
hip or knee
 Take home messages

• acute LBP is a diagnostic conundrum

• thorough history and physical exam
• CT/MRI findings can be misleading
• think laterally
 References

• General Practice, Murtagh J.

• Orthopaedics lecture series, PAH
• Harrison’s Principles of Internal Medicine
• Luke A Danaher