Makindo Medical Notes

⚠️ Do not perform imaging for low back pain in the first six weeks unless red flags are present. 🚩 Red flags include severe or progressive neurological deficits, or suspected serious underlying conditions such as osteomyelitis, malignancy, or fracture. Low back pain is very common, and most cases are benign and self-limiting. Always remain vigilant for malignancy, infection, fracture or neurological compromise (cauda equina syndrome).

🚩 Red Flags (Malignancy / Infection / Inflammatory)

• Age <20 or >50
• Night pain 🌙
• Persists beyond 6 weeks
• Elevated ESR or CRP
• Weight loss, cachexia, or known primary malignancy

⚠️ Worrying Diagnoses

• Multiple myeloma
• Metastatic cancer
• Tuberculosis osteomyelitis
• Bacterial osteomyelitis
• Spinal cord or root canal stenosis

🔍 Aetiology

• Mechanical (90%) – common in 25–55 yrs. Triggered by lifting/bending. Worse with activity, relieved by rest. Prognosis excellent (90% improve by 6 weeks).
• Malignancy – constant, progressive, night pain; weight loss, sweats, raised CRP. May present with neurological deficits or cauda equina.
• Inflammatory – axial pain, morning stiffness, age <40, sacroiliitis. Improves with exercise.
• Degenerative Disc Disease – root compression (often L4/5). Risk of cauda equina.
• Fracture – trauma relative to bone strength, steroids, osteoporosis. Pain focal with local tenderness.
• Infection (discitis/osteomyelitis) – constant pain, spinous tenderness, fever, IV drug use, immunosuppression, recent spinal procedure.

📊 Causes Table

🧪 Investigations

• FBC, U&E, CRP/ESR
• Calcium, phosphate, ALP, paraproteins (myeloma), PSA (prostate)
• MRI = imaging of choice if red flags
• Bone scan for infection/malignancy
• CT better for bony detail

💊 Management (Non Red Flag)

• Reassure – most resolve in 6 weeks
• Encourage activity, avoid bed rest
• Simple analgesia: paracetamol or NSAIDs
• Consider muscle relaxant or short course opioids for severe pain

📚 References

• Mechanical Low Back Pain – AAFP