💡 Back pain is one of the most common complaints in clinical practice. While most cases are mechanical and self-limiting, it is essential for clinicians to identify red flags that suggest serious pathology such as infection, malignancy, or neurological compromise.

📖 Clinical Approach to Back Pain

History: Onset, duration, location, radiation, aggravating/relieving factors, associated symptoms (neurological, systemic, urinary, bowel).
Red Flags 🚨:
- Age <20 or >55 with new back pain
- Night pain, progressive or non-mechanical pain
- History of cancer, weight loss, immunosuppression
- Fever, night sweats (infection)
- Saddle anaesthesia, bladder/bowel dysfunction (cauda equina)
- Unexplained neurological deficits
Examination: Inspect posture, palpate for tenderness, assess range of motion. Neurological exam of lower limbs: power, sensation, reflexes. Special tests: straight leg raise (sciatica), Schober’s test (inflammatory causes).

📝 Causes of Back Pain

Causes	Clinical Features	Investigations	Management
Mechanical Back Pain	Muscle strain: Sudden pain after lifting/twisting, localised, no radiation. Ligament sprain: Similar, with tenderness ± mild swelling. Degenerative disc disease: Chronic, worse with sitting/bending. Facet joint arthritis: Local pain, worse on extension/rotation.	Physical exam for movement restriction & tenderness X-ray for degenerative changes MRI if persistent pain	Activity modification, avoid prolonged rest Physiotherapy: core strengthening, stretching Analgesia: NSAIDs, paracetamol Corticosteroid injections if facet joint pain
Radicular Pain (Sciatica)	Shooting pain radiating down the leg Numbness, tingling, weakness Worse on coughing/sneezing	Straight leg raise positive MRI for disc herniation/nerve root compression Nerve conduction studies if unclear	Physiotherapy NSAIDs, muscle relaxants, neuropathic agents (gabapentin) Epidural steroids Surgery if neurological deficit or intractable pain
Spinal Stenosis	Bilateral leg pain, numbness, weakness Worse standing/walking (neurogenic claudication) Relieved by sitting or flexion	MRI: canal narrowing, nerve compression X-ray: degenerative changes, spondylolisthesis CT myelogram if MRI contraindicated	Flexion-based physiotherapy NSAIDs, analgesia Epidural steroids Laminectomy (surgical decompression)
Infectious Causes (Discitis, Osteomyelitis)	Severe constant pain ± fever, night sweats Not relieved by rest Risk: IV drug use, immunosuppression	Bloods: ↑ WCC, ESR, CRP MRI spine: disc/vertebral infection Blood cultures Biopsy for culture	IV antibiotics (long course, pathogen-directed) Analgesia Surgery if abscess/deformity Spinal brace for support
Neoplastic Causes (Spinal Tumours)	Persistent, progressive, nocturnal pain Weight loss, fatigue Neuro deficits, cancer history	MRI for tumour detection CT for bone detail Biopsy for histology Bone scan for metastases	Radiotherapy (metastatic) Surgical resection ± stabilisation Pain management: NSAIDs, opioids, adjuvants Chemotherapy depending on tumour type
Inflammatory Causes (Ankylosing Spondylitis)	Chronic back pain, morning stiffness improving with activity Sacroiliac joint pain Associated fatigue, ↓ spinal mobility	X-ray: sacroiliitis, syndesmophytes MRI: early inflammatory changes Bloods: ↑ ESR/CRP, HLA-B27	NSAIDs first-line Physiotherapy, posture exercises Biologics (TNF inhibitors) if refractory Encourage regular exercise

🔍 Investigations in Back Pain

Baseline: FBC, ESR/CRP, urinalysis (exclude UTI or renal causes).
Imaging:
- X-ray for fracture, degenerative change.
- MRI for soft tissue, discs, infection, malignancy.
- CT if bony detail required or MRI contraindicated.
Special tests: Bone scan (metastasis), EMG/nerve conduction (radiculopathy).

💊 Management Principles

Conservative: Education, reassurance, maintain activity, physiotherapy, weight management.
Pharmacological: NSAIDs first-line, consider weak opioids short-term, adjuvant neuropathic agents for radicular pain.
Interventional: Steroid injections, nerve blocks, epidurals for radicular pain.
Surgical: For cauda equina, instability, tumour, or severe refractory pain.
Rehabilitation: Encourage exercise, posture training, CBT for chronic pain.

✅ Key Teaching Pearls

Most back pain is benign and mechanical — reassure and keep active.
Always screen for red flags — cancer, infection, cauda equina, fracture.
MRI is the investigation of choice when serious pathology is suspected.
Back pain is often recurrent — long-term management requires exercise, education, and self-care.

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Back pain

📖 Clinical Approach to Back Pain

📝 Causes of Back Pain

🔍 Investigations in Back Pain

💊 Management Principles

✅ Key Teaching Pearls

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