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Back pain
Key points:
I) Any back pain stations if it is not acute then: Start
with psychosocial questions:
∙ How is it affecting your life?
∙ How is it affecting your daily activities?
∙ What do you do for living ?
∙ How is it affecting your job ?
∙ How is your mood ?
II) DDS of back pain:
1-AAA (abdominal aortic aneurysm
Pulsatile mass in the abdomen
2- Cauda Equina syndrome:
Unable to control urine, bowel & pain, and numbness
around the back passage
3- Multiple Myeloma:
DM (polyuria, polydipsia, weight loss) dt increase Ca
Decrease blood (RBCs: anaemia/ platelets: bleeding,
bruises/ WBCs: repeated infections)
4- trauma / fall / accident
5- disc prolapse:
Pain after lifting heavy objects
III) Always ask FLAWS ( to exclude cancer)
IV) If it is a male & old age, back pain ask about prostration:
∙ Difficulty in starting urination
∙ Weak stream
∙ Terminal dribbling
V) In examination:
∙ Observation

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 ∙ Back
∙ Back passage (PR)/ prostate
∙ Tummy (AAA)
∙ SLRT (disc prolapse)
VI) In management:
∙ Don’t forget pain killers
∙ In investigations: (x-ray back )
∙ Safety netting always (Cauda equina): if unable to control
urine/ bowel/ pain around the anus come back

Scenario 1 ( back pain AAA):

You are an FY2 in A&E department Adam 55 yrs old
came complaining of back pain since yesterday talk to
him , manage him and address his concern
Hi, I am dr …., are you ….?

How can I help you?

No psychosocial as it is acute pain

Tell me more?

SOCRATES

S: site : can you point with one finger to the site of the pain

O: how did the pain start?

C: character (type) of pain

R: Radiation: does this pain go anywhere else?

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A: Is there anything that makes the pain worse or

better?

T: time: How long have you had this pain?

E: Does anything relieve the pain?

S: severity on scale from 1 to 10 when 1 is the mildest pain and 10 is

the most severe, how would you grade it?
1) Questions +ve in AAA:
⮚ Back pain
⮚ Abdominal pain
⮚ Pulsatile mass in the abdomen
⮚ Have you ever had a scan on your tummy where you were told
that you have an abnormal blood vessel in your tummy 2)
Questions to exclude complications of AAA:
Fainting/ dizziness/ light headedness
3) Questions to find about risk factors:
P3 (smoking/ diet)

P2 (HTN/DM)

MAFTOSA ( family hx)

Then the rest of DDS:

⮚ Have you hurt your back or had a fall, accident, play

sport (trauma)
⮚ Are you unable to (control urine/ control bowel/
pain& numbness around back passage) = cauda equina
⮚ FLAWS + DM symptoms (polyuria- polydipsia-weight loss) +
decrease blood ( RBCS: anaemia/ platelet: bleeding & bruises/
WBCS: infection)= multiple myeloma

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⮚ Pain in the back that radiates to the back of legs, pain started
after lifting heavy weight
⮚ FLAWS

P2:

⮚ Have you had any back pain before?

⮚ Any medical conditions? (HTN/ DM/ cholesterol/ heart vimp
‫( هامه هامه‬problem
P3:
DESA (diet / smoking vvimp/ alcohol)
MAFTOSA
(family hx of abnormal bvs in tummy)
Examination:
⮚ Observations
⮚ Back
⮚ Tummy (tenderness above umbilicus & pulsations over the
abdomen)
⮚ PR (back passage)
⮚ SLRT

Provisional DX: (AAA abdominal aortic aneurysm)

We all have a big blood vessel or tube in our tummy called aorta this
blood vessel sometimes bulge and increase in width and become thin
and swollen and starts to leak causing back pain

Management:
1- Admit
2- Senior

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 3- Investigations :
⮚ Blood (CBC/ blood group/ cross matching) vvvimp + routine
blood
⮚ US scan on tummy
4- Symptomatic: O2 + fluids IV
Life style: we can arrange a meeting about lifestyle
modification
5- Specialist:
Refer to vascular surgeon depending on the size of aneurysm &
leaking or not
⮚ Open aneurysm repair: a cut in tummy & graft will be
placed
⮚ Endovascular repair : a graft will be inserted through a
blood vessels in your groin
6- Safety netting:
Dizziness or feeling you are about to faint inform
us immediately

Scenario 2 (back-pain due to trauma , pt played

squash)
You are an FY2 dr in A&E Rio 26 yrs old came with
sudden pain take hx and manage Hi, how can I help
you?
Can you tell me more about your back pain (SOCRATES) for 4
days
Psychosocial :
⮚ How is it affecting your life?
⮚ How is it affecting your daily activities?
⮚ What do you do for living?
⮚ How is it affecting your job?
DDs:

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 I) AAA ( ask about previous questions for AAA): Tummy pain /
pulsatile mass / have you had a scan where you were told
you have abnormal blood vessel in your tummy
II) Trauma ( did you sustain any trauma or fall or accident or any
sport) yes then explore , have you had this pain before or
after the sport
III) Disc prolabse:
⮚ Has the pain started after lifting heavy
weight suddenly
⮚ Do you feel that pain is radiating to the back
of your leg?
IV) FLAWS + DM symptoms (polyuria/ polydipsia/ weight loss) +
decrease blood ( RBCS: anaemia/ WBCS: infection/ platelet:
bruises & bleeding) = multiple myeloma

P2:

⮚ Have you had this pain before?

⮚ Any medical conditions?

P3:

DESA

MAFTOSA

Examination:

⮚ Observations
⮚ Back (tenderness over paraspinal area)
⮚ Tummy
⮚ SLRT (+ve)

Provisional DX:

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 From what you have told me it seems that you have muscle sprain
( you have overstretched your muscles after sports) it’s self-limited
, will subside on its own

Management:
1- No admission
2- Senior
3- No investigations needed
4- Symptomatic pain killers (advice to rest unlike disc prolapse)
5- If not relieved after two weeks refer to physiotherapist
6- Safety netting (pain not relieved or cauda equina symptoms)
7- Follow up

Scenario 3 (back pain due to disc prolapse): You are

an FY2 in emergency department Scott 30 yrs old
came with back pain take hx and manage him
Hi, how can I help you ?
P1: Back pain
SOCRATES

Radiation to the back of legs

SO
⮚ It radiates to back of legs
⮚ Started after lifting heavy weight

Psychosocial:

DDS:
1- AAA
2- Multiple Myeloma (FLAWS + DM symptoms + Decrease blood)
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 3- Trauma/ sport/ accident / fall
4- Cauda equina symptoms ( unable to control urine/ bowel/ pain
around back passage)
FLAWS

P2:

⮚ Have you had this pain before?

⮚ Medical conditions

P3:
DESA

MAFTOSA

Examination:

⮚ Observations
⮚ Back
⮚ Tummy
⮚ Back passage
⮚ SLRT (+VE) vvvimp
Patient will be lying down on his back on an examination table,
examine you lift the patient leg while knee is straight between
(30-70) pain

Management:
1- Senior
2- Investigations
⮚ Blood routine
⮚ X-ray back
⮚ MRI by orthopaedic
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 ⮚ US tummy
3- Symptomatic
Pain killers
4- Refer to physiotherapist (most improve)
5- Refer to surgeon if pain persists after 6 weeks 6-
Safety netting (cauda equina)
N.B: make sure advice about lifestyle modification and to
avoid lifting heavy objects or change their job if it is the cause
Sick note

Here advice to slowly (+/-) activity

Scenario 5 (multiple myeloma back pain)

You are an FY2 in GP 65 yrs old James came with back
pain for long time he had blood tests that showed (
anaemia decrease RBC/ blood electrophoresis
increases IgG / urine Bence jones protein/ decrease
platelets)
My approach, I can see from my notes that you are coming for
the test results
Is it okay if we have a chat in order to be able to explain things in
a better way
What made you come for these tests in the first place?

P1: back pain SOCRATES

DDS:
1- Multiple myeloma:

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 ⮚ DM ( it doesn’t cause DM , but it causes DM symptoms dt
increase Ca so easy to remember : polyuria- polydipsia-
weight loss ) Bones/ moans/ groans/ stones/ sitting on the
king throne
⮚ Blood components: (RBCS: anaemia: tiredness/ SOB/ heart
racing)
Symptoms of decrease WBCS (recurring sore throat/
fever/ cough)
Symptoms of decrease platelet (bleeding easily and
bruises)
⮚ FLAWS
2- Trauma / accident/ fall / sport
3- Disc prolapse questions (2 questions)
4- AAA
5- Cauda equina
P2:
⮚ Back pain before?
⮚ Past medical conditions?

P3:
DESA

MAFTOSA Family hx of cancer Examination:

⮚ Observations
⮚ Back
⮚ Back passage (PR)
⮚ SLRT
⮚ Abdomen (hepatomegaly / splenomegaly/ Lymphadenopathy)
vvvimp

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 Provisional DX:
First explain the blood results you had to remember

Then breaking bad news

Well from the information we have and those blood tests, I

am suspecting that the best case scenario is that you have some
abnormalities in your blood or in the worst case scenario, as you
mentioned you have lost… kg in… time, it could be multiple myeloma.
So I would like to exclude (multiple myeloma) which is a cancer in the
spongy tissue that present in some of our bones like ( spine/ skull/
pelvis and ribs)

Management:
1- Senior ( as you are in GP)
2- Investigations ( has been done in GP)
3- Symptomatic (pain killers) Morphine
4- Referral urgent to haematologist (blood specialist)
⮚ Bone marrow biopsy ( sample of your bone marrow)
⮚ MRI

Multidisciplinary team:

⮚ Psychologist
⮚ Physio therapist
⮚ Occupational therapist
⮚ Dietitian
⮚ Clinical and palliative physicians

Dr, what are my options of treatment?

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 1- Anti- myeloma medicine: to destroy myeloma cells & control
cancer when it come back
2- Medicine & procedures to prevent problems caused by MM
such as bone pain, bone fracture
NB : your job in this station is pain killer

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