BACK PAIN

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Back pain: pathogenesis, diagnosis and management NS672 Walker J (2012) Back pain: pathogenesis, diagnosis and management. Nursing Standard. 27, 14, 49-56. Date of acceptance: September 14 2012.

Abstract Back pain is a common problem that may have physical and psychosocial consequences for the patient if not managed effectively. Assessment should aim to identify any underlying pathology so that targeted treatment can be provided. The nurse has a central role in giving the patient information about managing pain and offering support and reassurance if pain persists.

Author Jennie Walker Clinical educator, musculoskeletal and neurosciences, Nottingham University Hospital, Nottingham. Correspondence to: [email protected]

Keywords Back pain, musculoskeletal disorders, orthopaedics, pain management

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

Aims and intended learning outcomes This article aims to provide an overview of common causes of back pain and some of the management strategies that can be used. After reading this article and completing the time out activities you should be able to:

© NURSING STANDARD / RCN PUBLISHING

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Describe the nature of back pain. Understand the different causes of back pain. List ‘red flag’ signs and symptoms of back pain. Identify factors that predispose individuals to chronic back pain. Outline different treatments used in the management of back pain.

Introduction Back pain is regarded as one of the most common musculoskeletal complaints, with many people experiencing back pain during their lifetime. Back pain is a symptom rather than a diagnosis; it may be caused by disease or injury, or may be a feature of systemic disease, sepsis or malignancy (Speed 2004). Back pain can also be caused by inflammation or mechanical features such as fractures, prolapsed discs or stenosis (narrowing of the spinal canal). It is important to be aware that many different structures in the back can contribute to back pain, including the joints, discs and connective tissues (National Institute for Health and Clinical Excellence (NICE) 2009). Pain may also radiate to the back from other structures such as the aorta or kidneys. The term non-specific back pain is used to describe back pain that is not attributed to a specified pathology or symptom pattern. An anatomical source cannot be identified in about 80% of people with back pain (McIntosh and Hall 2011), and a diagnosis of non-specific back pain is reached when the clinician is satisfied there is no specific cause for the pain. Complete time out activity 1 december 5 :: vol 27 no 14 :: 2012 49

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Learning zone orthopaedics Back pain can be discussed in relation to anatomical regions, such as the neck or lower back. Lower back pain may refer to pain, muscle tension or stiffness occurring between the costal margin and gluteal folds (Chou 2010). Some people may also experience referred pain to the upper legs, or radicular leg pain. Back pain can be described as acute pain typically lasting less than six weeks, subacute lasting six to 12 weeks and chronic persisting for more than 12 weeks (McIntosh and Hall 2011). While most patients recover reasonably quickly from an acute episode of back pain, some develop chronic symptoms. One of the main characteristics of lower back pain is its recurrent nature (Balagué et al 2012), with symptoms recurring in 50-80% of people within one year (Frymoyer 1988). This characteristic is a key element when considering back pain and factors that may predispose the individual to chronic illness.

Prevalence Back pain affects all age groups (Balagué et al 2012), although the reported prevalence varies significantly depending on the definition used. Ozguler et al (2000) reported an incidence of 8% when restricting the definition to cases requiring sick leave; however, when back pain was defined as pain lasting more than one day, incidence was reported as 45%. Discrepancy in initial definitions of back pain makes true comparison of data difficult. Jordan et al (2010) reported an annual prevalence of 417 consultations per 10,000 registered patients for lower back pain, with the highest attendance among those aged 45-64. Most episodes of lower back pain are self-limiting and not related to serious pathology, however it is important to identify patients with serious pathology promptly to ensure that treatment can be started without delay. Karahan et al (2009) studied the prevalence of back pain among hospital staff. They found that 65.8% of respondents had experienced back pain and, of those, 61.3% had experienced back pain within the previous 12 months. The highest prevalence was among nurses (77.1%), with 78.3% stating that their low back pain manifested itself after they started working in the hospital setting. Statistically significant risk factors included female gender, smoking, occupation and perceived work stress. 50 december 5 :: vol 27 no 14 :: 2012

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Anatomy The spine (vertebral column) consists of 33 vertebrae descending from the cranium to the coccyx. This includes seven cervical vertebrae, 12 thoracic vertebrae and five lumbar vertebrae, all of which are mobile segments; there are also five fused bones within the coccyx and four fused bones forming the sacrum. Between each of the mobile vertebrae are intervertebral discs, which flatten and change shape in response to compressive forces. Only limited movement is possible between individual vertebral bodies, but overall movement of the spine is extensive (Abrahams et al 2005). The greatest movement occurs within the cervical and lumbar regions as movement in the thoracic region is limited by attachment of the ribs to the sternum. The vertebral bodies and intervertebral discs are supported by ligaments and paraspinal muscles to maintain stability of the spine. The main ligamentous structures include the anterior longitudinal ligament, posterior longitudinal ligament, ligamenta flava and supraspinous ligament, all of which provide spinal stability. The spine has three main curves: cervical lordosis, thoracic kyphosis and lumbar lordosis. The degree of curvature of the lumbar lordosis can vary considerably between individuals and, in many instances, may decrease with age or as a result of poor posture (Oliver and Middleditch 1991). Abnormalities in the curvature of the spine include scoliosis, a lateral curvature and rotation of the spine. Collectively, the vertebral foramen form the vertebral canal, which provides protection for the spinal cord. Intervertebral foramina similarly are present between each pair of vertebrae, through which the spinal nerves, blood vessels and lymph nodes pass. The spinal cord originates at the medulla oblongata and extends down to approximately L1-L2, where it narrows to form the conus medullaris. The remaining nerve roots exit the spinal cord at this level and collectively form the cauda equina. There are eight cervical, 12 thoracic, five lumbar and five sacral spinal nerve roots. The area of skin innervated by the nerves is known as a dermatome, and innervated muscle groups are known as myotomes.

Diagnosis When patients present with a new episode or exacerbation of back pain, it is important to consider the cause of the pain or the reason


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for its exacerbation. Recording a detailed history about the nature of pain will include information about: Location. Onset – sudden or insidious. Radiation – whether the pain radiates to the legs. Exacerbating and relieving factors – whether the pain is worse after rest or movement. Associated symptoms, for example altered sensation or stiffness. Severity. During history taking, the clinician will try to identify the cause of pain and establish if there is a possibility that pain may be the result of a serious underlying complaint such as infection. It is imperative that malignancy, infection and fractures are diagnosed without delay to enable appropriate treatment to be initiated. Complete time out activity 2 Malignancy should be considered in older people and in those with a previous history of tumours known to metastasise to bone (NICE 2009). Infection should be considered in those with an impaired immune system or who are systemically unwell. These factors are often referred to as ‘red flags’ (Box 1). Complete time out activity 3 Yellow flags include psychosocial factors that may affect chronicity and how likely the patient is to make a full recovery from the episode of back pain. Management of psychosocial issues related to lower back pain can be complex and are best managed with involvement of a multidisciplinary team. Common yellow flags are listed in Box 2. Physical examination involves inspection of the spine and assessment of posture and spinal structures to identify changes in spinal alignment or saggital balance, which may contribute to back pain. Spinal movements include flexion, extension and lateral flexion of the lumbar spine, and may be restricted either through pain or physiological causes, such as the presence of osteophytes (bony projections) or fusion of the vertebral bodies. Neurological examination of the lower limbs should assess reflexes (patella and ankle) and the power and sensation of myotomes and dermatomes. This helps the clinician to identify if neural structures are being compressed. Documentation of neurological assessment provides baseline measures so that results of future examinations can be compared to see if the patient shows improvement or deterioration.


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Various imaging modalities are available to aid diagnosis of lower back pain, however not all patients require imaging. The use of radiographs still has a role in diagnosis, although magnetic resonance imaging (MRI) and computed tomography (CT) have enhanced the ability to view and diagnose problems that may be responsible for back pain. MRI is particularly useful for viewing the spinal canal as well as soft tissue structures such as discs, neural structures and ligaments. Due to the sensitivity of MRI imaging, degenerative changes of the lumbar spine may be observed that are part of the normal ageing process and may not be related to the present episode of back pain. Up to 50% of asymptomatic discs may appear to have degenerative changes (Speed 2003) and skill is required to determine clinically relevant changes. CT scans are an excellent tool for viewing fractures and bone tumours or metastatic lesions. The use of digital reconstruction can create three-dimensional images of the spine, which is particularly useful when evaluating the nature or extent of the pathology or planning surgical interventions.

BOX 1 Red flag signs indicating serious pathology as source of back pain Acute onset (with no identifiable cause). Constant or progressive pain. Fever. History of malignancy. Infection (recent or present). Neurological disturbance. Night sweats. Sphincter disturbance (bladder or bowel). Weight loss. (Speed 2004)

1 Consider your own experience of back pain or that of a patient. Describe the nature, duration, location, pattern and severity of pain, as well as any triggers and relievers of the pain. 2 What factors may lead you to suspect back pain may be caused by a serious underlying pathology such as infection, malignancy or fracture? 3 Think about factors that may affect how quickly people recover from an episode of back pain and consider what may be done to prevent prolonged recovery.

BOX 2 Yellow flag signs indicating possible chronicity of back pain Poor physical fitness. Poor self-rated health. History of low back pain. Radiating leg pain. Total work loss as a result of low back pain in the past 12 months. Disproportionate illness behaviour. Fear and attribution – what significance the patient gives to the pain. Low job satisfaction. Medico-legal proceedings. Personal problems, for example alcohol, marital and/or financial. Psychological distress and depressive symptoms. (National Institute for Health and Clinical Excellence 2009, Balagué et al 2012)

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Learning zone orthopaedics Non-specific back pain The pathophysiology of non-specific back pain remains poorly understood (Speed 2004). Pain is typically within the lumbosacral region and, although pain may be referred to the buttocks and thighs (poorly localised ache), back pain dominates over limb pain. Pain is typically described as mechanical in nature – it varies with physical activity, posture and over time (within and between episodes). Studies have noted a significant association between lower back pain and degeneration of the lumbar vertebral discs (Cheung et al 2009, de Schepper et al 2010). However, a systematic review by Endean et al (2011) concluded that the lesions found on MRI could not be identified as an individual cause of lower back pain. Many people with abnormalities seen on MRI remain asymptomatic, or findings do not correlate with the development of lower back pain (Balagué et al 2012). Complete time out activity 4 It is thought that the presence of tumour necrosis factor-α may have a pathophysiological role in the development of back pain (Jeffries et al 2007), as with obesity (Shiri et al 2010) and genetic factors (Battié et al 2007, Kalichman and Hunter 2008). Mechanical factors were thought previously to be causative in lower back pain (Balagué et al 2012), but systematic reviews have concluded it is unlikely that occupational sitting, awkward postures, standing and walking, bending and twisting, or carrying are independent causes of lower back pain (Roffey et al 2010a, 2010b, 2010c, Wai et al 2010a, 2010b). Complete time out activity 5 Non-specific lower back pain generally improves regardless of treatment (Devlin 2003a). For this reason, treatments for non-specific lower back pain focus on providing patients with education, advice and information that promote self-management and a speedy return to normal activities (NICE 2009). Patients should be encouraged to remain physically active and continue with normal activities as far as possible. In some instances, it may be helpful to suggest ways to increase the level of physical activity, without the cost of joining a gym. Such suggestions may include going for a walk every day, swimming or even exercising along with a fitness video at home. Although remaining active is difficult for patients in pain, bed rest is associated with increased joint stiffness, muscle wasting and 52 december 5 :: vol 27 no 14 :: 2012

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loss of bone mineral density, all of which can cause further problems (McIntosh and Hall 2011). Guidance on managing lower back pain is available (NICE 2009), however the complex biopsychosocial nature of lower back pain makes interventions difficult to evaluate. The aim of interventions for non-specific lower back pain is to relieve pain and improve function through the development of coping strategies. It is also important to reduce time taken to return to work following an episode of lower back pain and prevent the development of chronic pain. The use of manual and physical therapy strengthens supporting musculature and may help with postural and biomechanical irregularities. The use of back exercises may also reduce recovery time (Chou 2010, McIntosh and Hall 2011). However, there is considerable diversity in the definition of exercise and the differentiation between generic and specific back exercise. In chronic lower back pain, exercise and intensive multidisciplinary programmes are beneficial in reducing pain and improving function (Speed 2003). The biopsychosocial approach to rehabilitation may help prevent chronicity in patients who still have pain after the initial acute phase. However, multidisciplinary treatment programmes are often long processes and require good collaboration between the patient, rehabilitation team and patient’s workplace. This type of programme may not necessarily be needed for those with uncomplicated acute lower back pain, although it is important to consider the person’s expectations and preferences when considering treatments. It is important that nurses are able to identify the effects of lower back pain on outcomes, such as distress and disability, and develop clear goals with the patient and strategies to achieve these goals. Provision of written information containing positive advice on how to manage lower back pain such as The Back Book (Roland 2002) may further improve knowledge and attitudes, reduce pain and disability, and encourage self-management and a return to normal activity. The use of cyclooxygenase-2 (COX-2) inhibitors and traditional non-steroidal anti-inflammatory drugs may improve pain and function (Chou 2010), although these are associated with an increased risk of myocardial infarction (Kearney et al 2006), gastric ulceration and bleeding. Muscle spasm can be severe and restrict movement, although a short course of benzodiazepines may be helpful (van


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Tulder et al 2004). However, side effects of dizziness, drowsiness and potential addiction may occur (Chou 2010). Weak opioids may be considered for short-term use to enable patients to remain active (Balagué et al 2012), but are not advised for persistent non-malignant pain (British Pain Society 2010). Epidural corticosteroid injections can also provide a short period of improvement in those with leg-dominant pain and nerve irritation (Chou 2010, McIntosh and Hall 2011). Spinal manipulation is another approach to managing lower back pain, although it is not recommended for those with severe or progressive neurological deficit (McIntosh and Hall 2011). Furlan et al (2008) suggested that massage combined with exercise and education can be beneficial for patients with non-specific lower back pain, whereas Assendelft et al (2004) reported no significant advantage of manipulation over GP care, analgesics, physical therapy or exercises. Lumbar supports can provide additional support during episodes of back pain. Calmels et al (2009) reported elastic lumbar supports can significantly reduce pain at 30 days and at 90 days. However, prolonged use reduces the functioning of the lumbar spine and abdominal muscles and can lead to deconditioning of the muscles (Chou 2010). Other strategies include the use of acupuncture (Yuan et al 2008), heat therapy (French et al 2006) and transcutaneous electrical nerve stimulation (TENS). Nurses have an important role in providing advice on the management and prevention of lower back pain as well as teaching and supporting cognitive and behavioural strategies to cope with this type of pain. Nurses can offer advice on adopting good postural positions where possible when standing, sitting or driving. Examples of self-management strategies are provided in Box 3.

Prolapsed intervertebral disc Many spinal conditions can result in pain being referred to the leg. Compression of the nerve roots can cause radicular pain (radiculopathy), which closely follows the pattern of nerve distribution, whereas referred pain is more generalised. The most common cause of radiculopathy is a prolapsed disc (Speed 2004). Since intervertebral discs prolapse posterio-laterally, they compress the lower emerging nerve root (Figure 1). This causes pain and dysesthesia (altered


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sensation) in the associated dermatome. There may also be weakness of the associated myotome. Leg pain is generally reported to be worse than the lower back pain (Doran and Neumann 2004). Initial management should include the use of oral analgesics, education and reassurance, however the use of nerve root blocks or epidurals may be considered. As the pain resolves, physical therapy and physical reconditioning may commence. If no improvement is seen, further evaluation is required and surgical decompression may be considered (Devlin 2003a). Cauda equina syndrome can occur when the intervertebral disc prolapses centrally and compresses nerve roots as they descend the spinal canal. This causes a complex pattern of lower back pain, bilateral sciatica, saddle anaesthesia (numbness or altered sensation that

FIGURE 1 Prolapsed intervertebral disc

Vertebral body

Conus medullaris

Cauda equina

Prolapsed intervertebral disc

4 Consider the diagnosis of non-specific lower back pain and think about what information would be helpful for patients with these symptoms. You may wish to discuss this with a colleague. 5 Discuss with members of the multidisciplinary team different ways in which back pain can be managed, including pharmacological and non-pharmacological strategies.

BOX 3 Self-management strategies Moving and handling heavy weights carefully. Performing core abdominal strength exercises. Using hot or cold packs to reduce pain. Keeping active and avoiding bed rest. Following pain management programmes. Being aware of good postural positions, including avoiding bending or stooping, assessing driving and seated positions, and lying flat to sleep rather than sleeping in a chair or propped up with pillows. (Roland et al 2002)

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Learning zone orthopaedics affects the perineal and surrounding areas, typically the areas which would come into contact with a saddle if horse riding), urinary retention and faecal incontinence (Doran and Neumann 2004). Other pathologies that may cause cauda equina syndrome include tumours, infection and displaced fractures. Urgent MRI imaging is required to identify the cause of compression. Cauda equina syndrome is considered a surgical emergency and requires prompt surgical intervention to decompress the nerve roots (Devlin 2003a). Complete time out activity 6

Middleditch 1991) that is relieved when the patient stops to rest or adopts a flexed posture (Devlin 2003a). Many activities are difficult for this patient group, but cycling or walking uphill, or leaning on the supermarket trolley when shopping, enable the patient to adopt a forward flexed posture. In contrast, activities that require extension of the spine, such as walking downhill, would be considerably more difficult. Surgery may be indicated in patients with severe pain or progressive neurological deterioration (Doran and Neumann 2004).

Spinal stenosis

Inflammatory disease

Abnormal narrowing of the spinal canal, resulting in compression of the spinal cord and/or nerve roots, is known as spinal stenosis (Doran and Neumann 2004) (Figure 2). This may occur for several reasons, including facet joint arthrosis, hypertrophy of ligaments, presence of osteophytes and ‘bulging’ of intervertebral discs. Symptoms include back and leg pain, and psuedoclaudication, in which the patient experiences heaviness and discomfort in the legs when mobilising. This is caused by compression of the neural structures, which subsequently causes ischaemic pain (Oliver and

Spondyloarthropathy refers to one of the inflammatory arthropathies that affect the spine. These include ankylosing spondylitis, reactive arthritis and psoriatic arthritis. Pain and stiffness are more pronounced following rest, rather than mechanical activity, with patients experiencing morning stiffness that improves after activity. Management of spondyloarthopathy depends on the disease process, and is usually managed by the rheumatology team. Specific management for back pain and morning stiffness may include analgesics, anti-inflammatory drugs and exercise.

FIGURE 2

Spondylolisthesis

Spinal stenosis Spinal canal

Spinal stenosis

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Spondylolisthesis occurs when there is a bilateral fracture through the pars interarticularis, vertebral displacement occurs and the vertebra slips forward on the vertebra below (Figure 3). Spondylolisthesis may occur in the developmental stages or be acquired through traumatic, pathological or degenerative causes (Ginsburg 2004). If displacement of the vertebra is extensive or progressive, the nerve roots may become compressed and cause pain and neurological disturbance. For many patients spondylolisthesis is asymptomatic, with diagnosis being made through incidental radiographic findings. This group of patients may require no further intervention, and may be advised to contact the GP should they become symptomatic. Symptomatic patients may be managed using simple analgesics, physiotherapy, supportive braces or in some cases surgical fixation (Devlin 2003b). Modification of activities may be required if patients continue to be symptomatic, such as the restriction of movements that require hyper-extension of the spine.


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Surgery Various factors require careful consideration before surgical intervention, such as the need for surgery and psychosocial factors (Devlin and Enker 2003). If there is no appropriate indication for surgery, the procedure is less likely to be successful in treating the cause of back pain. Similarly, if psychosocial issues are considerable, then the surgical outcome may be negatively affected by these issues, with the patient making a poor recovery or less progress than would normally be expected (Devlin and Enker 2003). It is important to address the patient’s expectations and goals (Devlin and Enker 2003). The nurse has a key role in discussing patient expectations and can offer psychological and practical help throughout surgical planning and post-operative periods. Spinal decompression may be indicated in cases where there is symptomatic compression of the spinal cord or nerve roots, such as in prolapsed discs, spinal stenosis and impingement as a result of infection or tumour metastases. Spinal stabilisation may be performed when the structural integrity of the spine is compromised to prevent deterioration in neurology, spinal deformity and chronic pain. Indications for spinal stabilisation include spondylolisthesis, fractures or instability caused by spinal metastases (Doran and Neumann 2004). In the presence of spinal infection, a biopsy may be required for culture and sensitivity

FIGURE 3 Spondylolisthesis Vertebral column

Vertebral displacement


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testing so that appropriate antibiotics can be commenced. If the spinal cord or nerve root is compromised as a result of an abscess, this may be drained at this time. Similarly, if spinal malignancy or metastatic disease is suspected, a biopsy may be performed to obtain samples for histology. The decision to decompress the spinal cord or nerve roots for treatment for spinal tumours should be made in conjunction with the oncology team. Patients with serious spinal pathology often have complex needs and benefit from the involvement of specialist staff such as the palliative care team.

Outcome measures There are several measures of outcome, including: pain intensity scales, for example visual analogue or numerical rating scales; overall improvement, either observed or self-reported; medication use; functional status, determined using validated questionnaires such as the Oswestry (Fairbank et al 1980) or Roland Morris questionnaire (Roland and Morris 1983); and return to work. Most important are patient-centred outcomes, which should be acknowledged and used to inform the clinician’s decisions about patient progress and how back pain continues to affect daily activities.

Conclusion Lower back pain is a common but complex problem, which challenges people in many ways through the physical aspects of continuing with activities of daily living and managing the psychosocial issues related to recurring pain. It is important that significant pathology is identified and treated in a timely manner, however the treatment of non-specific lower back pain remains a challenge for all members of the multidisciplinary team. Nurses have an important role in managing back pain through assessing the nature of pain and providing information and reassurance about managing it. There are many different approaches to managing back pain, and the use of self-management strategies should be encouraged. Good communication between the patient and healthcare team will ensure that treatment takes into account patient needs and preferences and enables an effective partnership that promotes self-management and speedy recovery where possible NS Complete time out activity 7

6 Find out what services and self-help groups are available locally for patients who develop cauda equina syndrome. 7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60.

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Learning zone orthopaedics References Abrahams P, Craven J, Lumley J (2005) Illustrated Clinical Anatomy. Hodder Arnold, London. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004) Spinal manipulative therapy for low back pain. Cochrane Database of Systematic Reviews. Issue 1, CD000447. Balagué F, Mannion AF, Pellisé F, Cedraschi C (2012) Non-specific low back pain. The Lancet. 379, 9814, 482-491. Battié MC, Videman T, Levalahti E, Gill K, Kaprio J (2007) Heritability of low back pain and the role of disc degeneration. Pain. 131, 3, 272-280. British Pain Society (2010) Opioids for Persistent Pain: Good Practice. www. britishpainsociety.org/book_ opioid_main.pdf (Last accessed: November 15 2012.) Calmels P, Queneau P, Hamonet C et al (2009) Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine. 34, 3, 215-220. Cheung KM, Karppinen J, Chan D et al (2009) Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals. Spine. 34, 9, 934-940. Chou R (2010) Low Back Pain (Chronic). www.ncbi.nlm.nih.gov/ pmc/articles/PMC3217809 (Last accessed: November 15 2012.) de Schepper EI, Damen J, van Meurs JB et al (2010) The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic feature. Spine. 35, 5, 531-536. Devlin VJ (2003a) Lumbar disc herniation and discogenic lumbar pain syndrome. In Devlin VJ (Ed) Spine Secrets. Hanley & Belfus, Philadelphia PA, 272-278. Devlin VJ (2003b) Spondylolysis and spondylolisthesis in adults. In Devlin VJ (Ed) Spine Secrets. Hanley & Belfus, Philadelphia PA, 346-351.

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BACK PAIN

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