Acute low back pain inquality inspectorPatient historyMale patient, 32,Indian, presented to first aid room in residence camp with severe low back painof rapid sudden onset, around 6 hours ago, sharp but tolerable at onset withgradual progress into intolerable by noon, which drove patient to seek medicalattention. No specific factors provoked pain or triggered onset. Patient cannotrecall factors alleviating or worsening pain. Pain in lumbosacral area withoutstrict localization is constant and sharp, irradiates into thighs bilaterally.
Walking and sitting are painful, with grimace, gait is slow, painful. NSAID injectionoffered in first aid room and patient transferred for neurologist assessment. No previous historyof backache; denies recent back injury. General medical history unremarkable. Family history:unremarkable. Non-smoker, deniesalcohol consumption. Occupationalhistory:Current position:quality welding inspector, 4 years of employment. Routine requires frequentclimbing ladders to/from excavations, squatting (occasional, not repetitive),walking long distances (few kilometres per day), but rather occasionally, prolongedsitting in vehicle travelling between inspection points.
No manual handling,lifting, pulling or pushing of weights are required. Spends 1-2 hours a day attable in office for reporting and image interpretation. Normal work shift is 10hours, 6 days a week. No major changes to routine reported within last months. Workload is of moderate psychological demand with strict time frames of workcompletion, requiring reasonable self-pacing. Accuracy and precision of testinterpretation are mandatory. For the last yearpatient lives in residential camp.
He denies hobbies after business, preferringsedentary life. Clinical examinationAlert, completelyoriented, lying on couch because of severe lumbosacral pain. Notable hyperesthesia,does not allow touching any area of skin, screaming of pain at light touch.
Backpain irradiates to anterior aspects of both thighs. Allowed examination after IMinjected NSAID. Weigh 92kgHeight 168cmBMI32.6HEENT – unremarkablePulse 78BPM BP 121/75mmHgSpO2 98% room airT36.4°CNo respiratorydistress. System examination – unremarkable. Back examination –unremarkable except superficial dermal hypersensitivity in lumbar, sacral andgluteal areas.
Neurologicalexamination – unremarkable, reflexes normal, muscular strength 5/5, no sensory-motordeficit. Positive straight legraising test, no signs of cauda equina syndrome, or bladder dysfunctions. Schober test: flexion<5cm on pain. Forward flexion:painful, can reach knee level with fingers.
Lateral flexion: canreach knee with fingers (painful). Rotation seated oncouch: painful, limited. Investigations and results FBS119 mg/dl CBC– normal WBC10.74×103/µl RBC5.
27×106/µl HGB15.5 g/dlESR5 mm/HRCRP3.2mg/lThyroid, renal andliver functions – normal Lumbosacral AP x-ray– unremarkable Lumbosacral MRI imaging(neurologist order) – normalPatient admitted forinpatient management of pain. Diagnosis and treatmentNo red flagsidentified to suspect serious alternative diagnosis. Possible contributingrisk factors: obesity, static posture and vibration on rough terrain (whileriding vehicles).Waddell signs:superficial non-anatomical tenderness, overreaction to examination – possiblenon-organic component of pain present.
No organic changes onMRI and x-ray images (to rule out lateral disc protrusion), WBC 10.74×103/µl– possible inflammatory irritation of nerve. Admission Dx:Radiculopathy. Discharge Dx(neurologist): Back pain. Radiculopathy. In-hospitaltreatment: neurologist assessment, pain control: Ketorolac 30mg IM, Blokium-B12(Diclofenac 75mg + Hydroxicobalamine 10mg + Betamethasone 3mg) IM OD.
Neurologistprescription on discharge: Blokium-B12 IM OD 3days Tizanidine (Sirdalud)2mg t.i.d.
2 weeksArcoxia 90mg OD 2weeksNexium 20mg OD 7 days bed rest ondischargeCase management, occupational health management andprevention Patient consented forcommunications between hospital and in-house OH service, and OH service andemployer. After inpatienttreatment employee was discharged with 7 days bed rest. OH service re-assessed functionalcapability after sick-leave. Fitness evaluated against OGUK Standards.
Employeesatisfied requirements of Sections 2-11 Musculoskeletal Conditions and 2-22Medications of OGUK Guidelines. Employee resumed toduties with OH recommendations: – Returnto work and remain active. – Modificationof daily activities: shorter work time with gradual return to normal scheduleand activities, “avoid painful arcs of motion, and tasks that exacerbate backpain” (7) – climbing ladders, awkward postures, quick abrupt body movements. – Self-managementplan and education on condition, encourage participation in treatment.
Supervised exercise program. – Weightloss advice. Fitness validity wasnot withdrawn.
OH service considered factors that could influence return towork:- Youngage and general good health prior to acute illness – facilitate recovery. Previousfitness examination (11 months prior): elevated liver panel (<2-time fold)ALT, AST, GGT. Triglycerides 5.
6mmol/l, serum cholesterol 5.6mmol/l. Medicalfitness certificate issued for 2 years.- BMI31=obesityClass I may affect treatment response. – Earlydiagnosis and treatment should facilitate good treatment response.- STarT Back Screening Tool:Total score=5, sub-score=3: medium risk of long term disability.
More intensiveintervention and support is required. – Yellow flags:patient strongly believes and expects passive treatment would benefit more thanactive participation, inappropriate avoidance of active life, pain fear. – Employerin-house policy on return to work determined positive attitude and support fromemployer and OH service.
Employer was advised on work place modificationsrequired for treatment. Education andinformation most important for prevention as no specific work placemodification is required. Follow upAfter 2 weeksoutpatient treatment employee returned to specialist revision. Lumbosacral painmarkedly alleviated and remains localized, come-and-go pattern, tolerable mostof the time.
As coping technique employee preferred longer lunch breaks lunchand shorter work hours. GeneralAnxiety Disorder Assessment GAD7 score: 0/21 (anxiety– none).PatientHealth Questionnaire PHQ9 scored 1/27 (depression –none).
Movement range: canreach mid-calf with fingers. No other movement restrictions. Taking into accountmedium risk of disability development and yellow flags neurologist referredpatient for 6 sessions supervised group exercise program in Sports InjuryCenter.Arcoxia and Nexiumcourse continued for another 2 weeks. 2months follow-up: STarT Tool re-evaluation – total score and sub-score=1. Yellowflags blurred. Patient admitted positive effect of group and self-pacedexercises.
No days away from work reported. Patient still preferred self-pacedlonger mid-day breaks and shorter work time because of low levels of pain onsome days. NSAID (Ibuprofen 400 mg) prescribed when needed for pain. 4months follow-up: patient reported completerecovery, no symptoms of low back pain. Full range of movements. No furthertreatment and follow-up visits required. Importance of staying activeemphasized. Employee returned to full duties.
Discussion Low back pain (LBP) iscommon condition. 60-80% of UK population, 90% of US population, and 50% ofworking population experience it at some time, peaking at age 35-55 year. 85-90%of LBP is simple or mechanical pain, nonspecific with no attribution to seriousspecific causes. Prolonged standing,awkward static posture, poor lifting technique, high physical job demand, repetitivemovements bending are potential risk contributors, but role is poorlyunderstood.
Psychological factorscan contribute to chronization and poorer outcome of treatment. In majority of casesLBP is self-limiting and recovery is expected 90% within 6 weeks. Comprehensive historywith flags and physical exam allow to identify patients with seriousconditions. Pain referred from other regional organs should be considered.
Diagnostictriage helps to exclude alternative diagnosis: infection, injury and otherspecific causes. Patient riskassessment and stratification with psychological assessment (yellow flags) shouldbe done at early contacts with health services (STarT tool). More complex careand intensive support should be considered for patients with increased risk ofchronic LBP development.
Imaging for simpleLBP has limited application and should be performed in specialist care setting.Plain x-ray has low diagnostic yield for LBP and rarely needed for initialevaluation. MRI and CT-study could be considered in patients with progressiveneurologic deficit and systemic symptoms to rule out underlying cause.
Clinical findingsdetermine laboratory works to differentiate infection and malignancy. Patients shouldunderstand nature and ethology of pain and receive adequate reassurance, educationand information to stimulate patient to maintain active life, early return to workand normal daily activities. Role of active participation in treatment andself-management should be emphasised. Patients withmoderate risk should receive multidisciplinary approach to minimize long termdisability, absenteeism and employment loss. Cognitive behavioural therapies,manual therapies and supervised group exercise programs benefit to overcomeobstacles for recovery. Prolonged bed restmust be avoided.
2-3 days of bed rest in supine position could be offered foracute radiculopathy. Instead, activity modification is preferred to “avoidpainful arcs of motion and tasks that exacerbate back pain”. Referral to physicaltherapy, manipulation and multidisciplinary treatment should be considered asearly as 1-2 weeks(10), and offered if patient does not return towork within 6 weeks(12). NSAID at lowesteffective dose should be prescribed for pain relief for the shortest reasonabletime, reserving weak opioids for cases not controlled by NSAID and rescueanalgesia. Opioids should be avoided for management of chronic LBP. Selectiveserotonin reuptake inhibitors, tricyclic antidepressants and anticonvulsantsshould be avoided in pharmacological management. Muscle relaxantscould be considered for short course.
Effectiveness of VitB12 and steroids have not been confirmed. Thus, there is no place and role forcyanocobalamin and betamethasone in treatment of acute LBP. Paracetamolmono-therapy is ineffective and should not be prescribed. Patients, who do notimprove, worsen or do not return to work within few weeks after onset and startof treatment should be reassessed and alternative reasons for LBP withalternative treatment to be considered.