🩺 Back Pain

Back pain is one of the most common reasons for primary care consultations in the UK. While the majority of cases are 'non-specific mechanical back pain' that resolves within weeks, it can also manifest as life-threatening emergencies like Cauda Equina Syndrome (CES) or Metastatic Spinal Cord Compression (MSCC). Management follows a stratified approach: reassurance and analgesia for low-risk patients, and urgent imaging and surgical referral for those with 'red flags'. Assessment must incorporate both physical and psychosocial factors.

Focus on the 'red flags' which indicate serious underlying pathology: cancer, infection, or Cauda Equina Syndrome. Ask about the duration, site, and radiation of the pain, as well as any history of trauma. Screen for systemically unwell features like fever or unexplained weight loss. Occupational history and psychological stressors (yellow flags) should be explored to assess the risk of chronic disability. Inquire about nocturnal pain which is characteristic of inflammatory causes like ankylosing spondylitis or malignancy.

Observe the patient's gait and spinal posture, looking for scoliosis or loss of lumbar lordosis. Palpate the spinous processes for focal tenderness (suggestive of fracture or infection). Conduct a thorough neurological exam of the lower limbs, including power, reflexes, and sensation (L2-S1 dermatomes). Perform the straight leg raise test; a positive test (reproduction of leg pain between 30-70 degrees) is sensitive for disc herniation. In suspected Cauda Equina Syndrome (CES), a perianal sensory check and digital rectal exam (DRE) for anal tone are mandatory.

Mechanical Back Pain, Lumbar Disc Herniation, Spinal Stenosis, Ankylosing Spondylitis, Metastatic Bone Disease, Spinal Epidural Abscess, Cauda Equina Syndrome.

Saddle anaesthesia, bladder/bowel dysfunction, bilateral sciatica, night pain, fever, weight loss, and history of IV drug use or malignancy.

For simple mechanical back pain, no imaging is required according to NICE guidelines. If red flags are present, urgent MRI of the whole spine is the definitive investigation (especially for CES or metastatic compression). Blood tests such as FBC, CRP, and ESR are useful if infection or malignancy are suspected. Bone profile and Myeloma screen (Urinary Bence-Jones protein and serum electrophoresis) should be considered in elderly patients with new-onset back pain. Bone scans or CT may be used if MRI is contraindicated.

True radicular pain (sciatica) usually travels below the knee; pain confined to the buttock is less likely to be nerve root compression. Mechanical back pain normally improves with light activity—strict bed rest is no longer recommended and may actually delay recovery. Always ask about 'saddle anaesthesia' and bladder/bowel dysfunction; even a single episode of urinary incontinence in the context of back pain is an emergency. Weight loss and night pain must always raise suspicion of malignancy or infection.

Back pain is a highly common presentation in both General Practice and Orthopaedics. The MLA expects students to confidently identify 'red flags' and 'yellow flags' (psychosocial barriers). Understanding when NOT to image is just as important as knowing when to order an urgent MRI for suspected cord compression.