CHRONIC LOWER BACK PAIN
● Chronic if >3months
● Risk factors: extreme height, smoking, morbid obesity, psychological issues,
industrial societies
● aggravating factors: prolonged sitting/standing, working with arms elevated and away
from body, bending forward
● Relieving factors: walking, constantly changing positions, reclined
● Aims of patient management: if duration >12 weeks → determine cause
(x-ray, CT, MRI), treat cause, reduce pain and increase functionality
● Radiculopathy Dx: reduced power, reflexes, sensation in distribution of involved
spinal nerve
● Red flag Hx indicating urgent investigation/Mx:
○ Cancer: Hx with new onset low back pain, weight loss, failure to improve after
1 month, >50yrs, night pain
○ Vertebral infection: fever, IVDU, recent infection, immunocompromised state,
rest pain
○ Cauda equina syndrome: urinary retention, faecal incontinence, saddle
anaesthesia, lower limb weakness/numbness
○ Vertebral fracture: Hx osteoporosis, corticosteroids, older age, Hx falls/trauma
○ Ankylosing spondylitis: morning stiffness, improvement with exercise,
alternating buttock, awakening due to back pain during 2nd part of night,
younger age
● Indications for imaging: red flags, abnormal neurology, pain >4 weeks
● Mx:
○ 1st line: simple analgesic + non-pharmacological
■ Paracetamol 1g 4x/day, hot/cold packs, activity, strengthening
exercises, physical therapy
○ 2nd line: multidisciplinary rehabilitation + pharmacological - paracetamol,
opioids (short term use), NSAIDs, lyrica (pregabalin) for neuropathic pain,
topical analgesics, epidural steroid injections
○ 3rd line: surgical referral - surgery limited role, decompressive surgery (spinal
stenosis), discectomy (radiculopathy due to herniated lumbar disc)
● Broader GP Mx:
○ Review after 1 week → not adequate relief → 2nd line care
○ Sudden changes in pain levels/failure of Mx → return for adjustment
to management
○ imaging/pathology reserved for patients with suspected serious
pathology/radiculopathy
● Chronic if >3months
● Risk factors: extreme height, smoking, morbid obesity, psychological issues,
industrial societies
● aggravating factors: prolonged sitting/standing, working with arms elevated and away
from body, bending forward
● Relieving factors: walking, constantly changing positions, reclined
● Aims of patient management: if duration >12 weeks → determine cause
(x-ray, CT, MRI), treat cause, reduce pain and increase functionality
● Radiculopathy Dx: reduced power, reflexes, sensation in distribution of involved
spinal nerve
● Red flag Hx indicating urgent investigation/Mx:
○ Cancer: Hx with new onset low back pain, weight loss, failure to improve after
1 month, >50yrs, night pain
○ Vertebral infection: fever, IVDU, recent infection, immunocompromised state,
rest pain
○ Cauda equina syndrome: urinary retention, faecal incontinence, saddle
anaesthesia, lower limb weakness/numbness
○ Vertebral fracture: Hx osteoporosis, corticosteroids, older age, Hx falls/trauma
○ Ankylosing spondylitis: morning stiffness, improvement with exercise,
alternating buttock, awakening due to back pain during 2nd part of night,
younger age
● Indications for imaging: red flags, abnormal neurology, pain >4 weeks
● Mx:
○ 1st line: simple analgesic + non-pharmacological
■ Paracetamol 1g 4x/day, hot/cold packs, activity, strengthening
exercises, physical therapy
○ 2nd line: multidisciplinary rehabilitation + pharmacological - paracetamol,
opioids (short term use), NSAIDs, lyrica (pregabalin) for neuropathic pain,
topical analgesics, epidural steroid injections
○ 3rd line: surgical referral - surgery limited role, decompressive surgery (spinal
stenosis), discectomy (radiculopathy due to herniated lumbar disc)
● Broader GP Mx:
○ Review after 1 week → not adequate relief → 2nd line care
○ Sudden changes in pain levels/failure of Mx → return for adjustment
to management
○ imaging/pathology reserved for patients with suspected serious
pathology/radiculopathy
