Back pain - you must first exclude a serious diagnosis

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In the diagnosis of back pain again one should always think of the cause because this gives clues about treatment. The questions which always go through my head in every case of back pain are:

Anatomical problem with nerve pressure symptoms:

eg trauma, slipped disc, tumour, collapsed disc

Referred pain from chest or gout or skin:

eg shingles, kidney, ureter and bladder

Back pain from:

Arthritis, osteoporosis, allergic muscle, fibromyalgia

Is there a cancer?

If the back pain arose for the first time ever in an older person with no history of trauma then I would want to investigate it at once with blood tests, X rays (cheap and quickly available, some radiation exposure, may not pick up cancer)and possibly bone scan (lots of radiation) or MRI scan (ideal but expensive - no radiation exposure). I would be thinking to exclude cancer or other such lesions causing pressure. If there was a new pain in the back which that person has never experienced previously which did not improve with treatment of poor posture, then I would want further investigations doing.

Is there compression or pressure on the spinal cord?

This should be considered in any major trauma and investigated urgently. The back and neck must be held rigidly straight to prevent further movement. This is a job for an orthopaedic surgeon. People with rheumatoid arthritis may have an unstable neck anyway and should be especially cared for.

I ask about disturbances of sensation over the buttocks, groin and between the legs, whether or not there is any problem peeing, whether there is any problem passing faeces. Is there any weakness of muscles? If so, urgent investigation is needed.

Pain in the back which gets worse after walking a few yards up hill, improves with a few seconds rest, but returns with walking again suggests a spinal narrowing and needs fully investigating with MRI scan and consultant opinion.

Is there a slipped disc?

This is nearly always a disc of the lumbar vertebra and causes pressure on the sciatic nerve which supplies the leg. Pain is felt in the back and buttocks and spreads down the leg to the knee, foot and sometimes into the toes. This pain is called sciatica. A straight leg raise makes this pain worse and the reflexes at the knee (easy to test - compare both sides) and ankle (hard to test) may be sluggish.

A slipped disc is due to the "shock absorber" between the vertebral bodies getting squeezed out behind. To allow this to return to its normal place you need to lie horizontal on your tummy as much as you possibly can. Get someone to pull your legs out behind you (gentle traction) for a few seconds (some people hang from a bar to provide a bit of traction). When the acute pain is settled, do lazy press-ups - see Poor posture

Is there meningeal irritation?

The spinal cord is covered by three membranes called the meninges (the pia, arachnoid and dura mater). These are extremely sensitive and the slightest disturbance causes severe pain. If they have undue pressure on them you will know about it! The slightest movement or jolt is agony. One test for meningism is to put the chin on the chest, or straight leg raise (or both at the same time) - the pain will get much worse - do this cautiously.

Do not allow your back to be manipulated if you have these acute symptoms.

Is this osteoporosis?

Osteoporosis should be suspected in the following patients:

Underweight or malnourished (including anorexia, or a past history of anorexia)

Unable to exercise - CFS, lounge lizard

Pesticide or chemical poisoned

Early menopause

Family history

History of recurrent fractures, or fracture following minor blow

Medication - steroids, proton pump inhibitors

Western diet!

It is diagnosed by bone density scanning. These scans are remarkably accurate and can be done at any time of life after the age of about 40 (when the bone density should be at its best) and will give a good idea of whether or not you have osteoporosis or if you are going to get it.

Is this allergic muscles?

See Allergic muscles.

Are there any other symptoms?

Shingles can cause back pain before the rash appears.

Problems in other areas can present with back pain:

Loin pain suggests kidney

Lower back pain can occur in any abdominal problem

Pain between the shoulder blades could be oesophagus, or thoracic aortic aneurysm.

Pain in the upper part of the chest could be lung related

Pain in the shoulder could be diaphragm problem (eg from an ectopic pregnancy)

Is it worth getting an X ray done?

The trouble with X rays is that they do cause quite a significant exposure from radiation. That is why I do not refer patients through this website for X rays (Hippocratic oath - "first of all do no harm"). MRI scans are brilliant and there is no radiation exposure, but they are expensive. They are available at clinics such as LIFESCAN.

X rays visualise bone well, but soft tissue not so well. Arthritic changes can be seen, but slipped discs cannot. X rays should not be relied upon too heavily for diagnosis.

Poor Posture

The commonest cause of back pain in young people is poor posture. Back pain is an extremely common problem and largely arises from the fact that humans were never designed to stand up. The back evolved in a horizontal position and we would be much better off if we went around on all fours. It only works at all because of huge blocks of muscle, especially in the lower lumbar spine, which hold the back in the correct position. This is until we get unfit or lazy or both.

Look at a picture of a gorilla. Now that is the correct position for the back! Bum stuck in the air, shoulders stuck in the air, stomach dangling down towards the floor. One can achieve this comfortably on all fours. The difficult bit is holding this position at all times whether standing or sitting. It takes conscious effort initially, with time it is done automatically. One thing is for sure - if you find a conventional flat chair comfortable, then you probably not sitting properly!

If you struggle for an easy solution, go and see a professional eg osteopath, chiropractor, or take up Pilates or Alexander technique.

In older people there is often a combination of poor posture and arthritis, - see Essential fatty acid profile

Recommended reading: "Treat Your Own Back" by Robin A. McKenzie

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