There are three joint pain calls you might receive whilst you're on call or on the wards. We have split them into three articles (with links below) allowing us to expand appropriately for each section.
Overview of the Assessment
Back pain is incredibly common and usually no definite anatomical diagnosis is found (non-specific back pain). During your on call, your focus will be on recognising serious pathology and relieving pain. However, do consider the huge impact back pain can have with significant physical disability & psychosocial impact. Your aims when assessing back pain include:
  • Recognise serious pathology
    • This includes neurosurgical emergencies, infection (discitis/epidural abscess), malignancy, myeloma, osteoporotic wedge fractures and paget’s disease
    • Don’t forgot about referred pain - an aortic aneurysm could cause thoracic pain.  Pyelonephritis, renal colic and pancreatitis can all cause back pain
  • Relieve pain - see our article on pain relief. Focus on non-pharmacological agents & mobilising for chronic back pain. 
  • Recognise & assess any psychosocial impact 
  • Identify any barriers to recovery (yellow flags)
  • Prevent recurrence & persistence of symptoms
History
  • Site: Asking the patient to point to where the pain is can be helpful 
    • Directly overlying the spine suggests a bony cause 
    • Pain between the scapula could be referred pain from a dissecting thoracic aortic aneurysm or a MI 
    • Pain more laterally could be renal, pleuritic or referred from the hip
  • Onset: When did the pain first start? 
    • Is this a new pain? If not, what was the diagnosis & management last time?
    • What was the patient doing? Fracture, intervertebral disc pathology and musculoskeletal pain are often associated with trauma (fall, heavy lifting, sudden twisting motion)
    • Gradual or sudden?
  • Character
    • Sharp - spinal fracture
    • Muscule spasm
    • Pleuritic 
    • Neuropathic burning pain - nerve root compression
    • Tearing – aortic dissection
    • Crushing - MI 
  • Radiation 
    • Buttocks or legs – sciatic nerve compression 
    • Limbs – radiculopathy or spinal nerve root compression 
    • Flank to the ipsilateral groin – renal colic 
    • Epigastrium – peptic ulcer disease or pancreatitis 
  • Associated Symptoms 
    • Sensory/motor disturbance including bowel & bladder pathology – cord compression 
    • Lower urinary tract symptoms – renal colic or pyelonephritis 
    • Weight loss – malignancy 
    • Early morning stiffness – inflammatory joint disease 
    • Fever/chills – infection, vertebral discitis 
  • Timing: course & whether it is intermittent or continuous
  • Exacerbating/ Relieving factors 
    • Exertional or improves on rest – OA or fracture 
    • Improves on exercise - inflammatory arthritis 
  • Severity 
    • This helps monitor the response to analgesia
    • Often asking how much their normal activity is limited by the pain helps grade severity
    • What do they do at work? Does the pain affect their job? Can their job be modified to support them going back?
  • Past medical history & family history
Recognising Serious or Sinister Pathology: Red Flags
  • Age above 50 or below 20
  • New back pain or in a new region (particularly if non-lumbar)
  • Any changes to chronic pain
  • Pain at night particularly if it wakes the patient up
  • Constant pain or progressively worsening pain (musculoskeletal pain tends to improve when not moving)
  • Cauda equina syndrome: motor, sensory changes or change in bladder, bowel function. These are late signs where the damage may already be done
  • Malignancy: known malignancy or systemic symptoms such as fever, chills or unexplained weight loss
  • Fracture: prolonged steroid use, known osteoporosis, trauma, focal or bony tenderness
  • Infection: Intravenous drug use, diabetes, immunosuppression, fevers, tuberculosis exposure
Psychosocial Barriers to Rehabilitation that increases the risk of chronic back pain: Yellow Flags

  • Avoiding activity with extended bed rest
  • Psychosocial overlay: mood disorder or social withdrawal
  • Dissatisfaction with work
  • Lack of support or overprotective family
  • Expecting medical input only is required for recovery

Examination
  • General examination
  • Palpate & percuss each spinous process (infection, fracture or malignancy)
  • Look for paraspinal muscle spasm (common in prolapsed discs)
  • Palpate paraspinal muscles for tenderness (common in musculoskeletal causes)
  • Examine range of movement
  • Neurological examination – check for absent ankle reflexes (slipped disc) or long tract signs in the legs (UMN signs – spasticity, hyperreflexia, Babinski sign)
  • PR examination and test perineal sensation
  • Consider straight leg raise for sciatic nerve compression
  • If malignancy is highly suspected, 
Investigations
  • Usually no investigations are required for simple back pain
  • Imaging
    • A lumbar x-ray is the equivalent to 120 CXRs, avoid routine scanning
    • Consider a CT scan for stress fractures and spondylolisthesis
    • MRI is better for soft tissue e.g. discitis, suspected malignancy, spinal cord compression. If cord compression is suspected, urgently escalate & read this
  • Bloods including inflammatory markers & bone profile (ALP & calcium)
  • Consider protein electropheresis for myeloma
  • If suspecting malignancy, consider the more common cancers that affect the spine: multiple myeloma, lung, breast or prostate
Management
  • Advise the patient to stay active
  • Low dose, non-opiate analgesia is best. See our article on pain relief
  • Escalate if any cause apart from non-specific back pain is considered
References & Further Reading
Written by Dr Emma Monteith FY1
Edits by Dr Akash Doshi CT2