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The back pain problem

Case history 2

Mrs Smith is a 45 year old lady with a long history of mild chronic low back pain. She is referred because it has got a lot worse in the last 6 months. She has an irritable bowel syndrome, a sero-negative arthritis and a history of chronic headaches. In the past she has suffered from alcoholic abuse and was also habituated to Diazepam. However, she has been successfully weaned off both alcohol and Diazepam.

The back pain is now debilitating and she cannot do some of her household jobs and cannot drive for more than 5 minutes. There is no spread into the legs. She is stiff in the morning when she wakes, and then she gets a little easier. The pain then gets worse over the day with activity. It remains throughout the night, and keeps her awake.

What is the further management of this lady? Does she require further investigation?

She weighs 96 kilograms and is 1.6 metres tall. A straight X-ray of her lumbar spine shows disc degeneration at L4/5 and L5/S1. What is the value of this investigation?

MR scan shows disc bulging at S1 with no neural encroachment. How would you communicate this to the patient?

ESR is normal. She has a mild iron deficiency anaemia. Other bloodwork is normal.

On examination she has marked tenderness throughout the back, muscle spasm, a positive pinch test, pain on axial loading and pain on straight leg raising to 45 degrees. She can sit to 90 degrees. She puffs and pants throughout the examination. Her paravertebral muscles are extremely tight and tense, and she has a mild scoliosis concave to the left.

Do you require further information, or can you make a working diagnosis?

If so, what is the working diagnosis?

What is the management of this patient? Do you

1) Tell her to get on with it

2) Tell her to lose weight

3) Prescribe painkillers - ? which ones

4) Refer her to a Neurosurgeon

5) Refer her for physiotherapy

6) Use TENS

7) Get a Psychological opinion

8) Carry out a nerve block

If you were going to give her painkillers, what might you consider?

1) Paracetamol

2) Non-steroidals

3) COX 2 inhibitors

4) Opioid derivatives

5) Tramadol

6) Opioids

7) Anticonvulsants

8) Amitriptyline

9) Hypnotics

10) Muscle spasm relaxants

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