FCM WK1 CASE 1

FM&PH – Back Pain

module Family Medicine and Public Health

Gary Range has back pain. Back pain is a very common complaint but has considerable morbidity associated with it.

Back pain ILOs

Guidance and Resources – Back Pain

Case Introduction – Back Pain

Further Case Information – Back Pain

Background Science – Back Pain

Case Conclusion – Back Pain

Formative Assessment – Back Pain

CASE COMPONENT

Guidance and Resources – Back Pain

In case FM&PH – Back Pain

Recommended Essential Resources

     · Spine-health.com: Spine anatomy interactive video

· Patient.info: ‘Red flags’ in back pain

· Patient.info: Sciatica

Additinal Reading/Resources

· The most recent NICE guidelines are here. Most online resources are based on the older NICE guidelines; it’s useful to be aware of this.

· Patient.info: Terms used in relation to the back

· Patient.info: Spinal stenosis

· Example patient information leaflets:

· Information about assessing back pain using the STarT tool

· FRAX Tool

· Additional resource for further reading about physiotherapy

· Back Examination Text

CASE COMPONENT

Case Introduction – Back Pain

You’re sitting in with a GP in surgery and your next patient is Gary Range, a 40 year old carpenter. You haven’t met him before. You look through his medical notes before you call him in. He has seen one of the other GP’s in the surgery complaining of back pain. His PMH includes depression. He’s not on any prescribed medication, and doesn’t have any known drug allergies.

The GP asks you to start the history. You call Gary into the room; he walks in slowly, and with a limp. “It’s my back it isn’t better. I’m in so much pain, there must be something seriously wrong!”

https://youtu.be/BOjTegn9RuY

You ask him to tell you more about what’s been happening and how this has been affecting him. “I already told the other doctor all of this! Can’t you just read the notes?” You acknowledge his frustration but explain that it’s important to find out what has been going on since he was last seen and make sure you don’t miss out any important information. You then find out:

· Gary works fitting kitchen cabinets; he’s done this for around 20 years.

· He doesn’t remember the exact trigger of his back pain, but thinks it was because he had been lifting heavy boxes.

· He describes the pain as feeling tight and aching, as if his back goes tight.

· He doesn’t want to go back to his job now, he hates his boss.

· He says “it’s his fault he always makes me move the heavy boxes. I’m not going back to that job unless my back is ok. I don’t want to damage it. I’m fine when I rest my back, but it’s when I start to do anything. It really hurts here (he points to his lumbar spine). I thought I might need an X-ray, you know, maybe my disc has popped out. I’ve been suffering for 6 weeks now!”

Consider all the differential diagnoses you have at this stage, including those you think may be less likely. Select the diagnoses below to see how relevant they may (or may not be) be when considering Gary’s history.

NB: There are lots of terms that sound similar.

To clarify:

· SPONDY = spine

· SpondyLOSIS = degenerative

· SpondyLITIS = Inflammatory, this can be due to anything that results in inflammation.

· SpondyloLYSIS = “break down” of a bone typically a stress fracture of the Pars Interarticularis, classically seen as a Scottie dog fracture on an X-ray.

· SpondyloLESTHESIS = (to slip) – Slippage of a vertebrae body (not disc) typically due to a Pars Interarticularis fracture, but can also happen in degenerative conditions. This can cause nerve root compression.

CASE COMPONENT

Further Case Information – Back Pain

You review the notes which state that Gary had no red flag symptoms when he last consulted, but you check again.

Red flags are symptoms or signs that could potentially indicate a serious cause for the back pain.

Even though serious causes are less likely, it is always important to ask questions and examine for signs that help you rule out the serious differential diagnoses you have considered.

One condition which requires urgent attention if present is Cauda Equina Sydrome.

If there is compression of the spinal cord a patient develops myelopathy. The cauda equina ‘horses tail’ starts at L1 which is the end of the conus medullaris. This is where all the nerve roots come together. If compression occurs at the Cauda equina patients will have a specific set of symptoms that you MUST always ask about. This is a surgical emergency and needs immediate referral. If it is left untreated it can lead to permanent leg paralysis, and loss of bladder and bowel control!

Symptoms and signs you should ask about and examine for include:

Gary doesn’t have any red flag symptoms. He also has no symptoms or signs to suggest nerve root irritation or nerve root compression. There is more information about this in the background science tab.

Gary denies any neurological symptoms and the pain doesn’t radiate to the buttocks or the legs.

It’s not worse when walks. He is the same height as usual and his posture is unchanged.

“I’m scared of moving my back in case I do more damage. I haven’t been taking lots of painkillers, they just mask the problem and I might make my back worse, plus I don’t want to be addicted to them”. He may occasionally take paracetamol, he has taken 4 tablets in the last 2 weeks, but they didn’t seem to help.

You ask Gary if you can examine him:

Inspection: No obvious deformities (e.g scoliosis, or kyphosis. He doesn’t have ataxia).

Palpation: He has mild generalised pain in his lumbar spine L4, L5 area, no specific bony tenderness and has tenderness along the Lattisimus Dorsi bilaterally. He doesn’t have any pain in his thoracic spine.

Movement: You check his movements in all planes: flexion, extension, lateral flexion and rotation. He has limited flexion to 45 degrees, but the rest of his movements are normal, extension doesn’t cause any pain, he doesn’t have paraspinal muscle tenderness. His straight leg raises are limited by hamstring tightness rather than pain and are both 45 degrees. He is able to walk on both his heels, and toes.

Neurological findings: Sensation is normal. Ankle, and knee reflexes are present. He has no clonus and both plantars were down going.

The GP uses the STarT tool to help with shared decision making and planning further management with the patient.

The NICE recommended tool can be used for back pain in primary care to identify patients that are more likely to have longer term back symptoms.

Gary agrees with questions 3-8 and mentions that his pain is ‘extremely’ bothersome in question 9.

He scores 7. This makes him high risk.

The GP informs you after the consultation that he identified that Gary has some yellow flags, and these may be contributing to his delayed improvement.

Yellow flags are usually social and psychological cues derived from the bio-psycho social model of illness that may indicate that the patient is at risk develop chronic back pain.

CASE COMPONENT

Background Science – Back Pain

Back pain is extremely common in the KSA, with:

·  53-79% of the population complaining of this in their lifetime.

· It is a leading cause of disability and absence from work in the KSA and globally.

There are multiple causes of back pain, with the majority of this being self-limiting, but they can cause significant disability. It is important that we don’t miss the less common but serious causes of back pain.

You can go to this link to find the most recent NICE guidelines. Most online resources are based on the older NICE guidelines, it’s useful to be aware of this.

Anatomy Revision

Radiation down a specific nerve root can cause symptoms that are sensory, nociceptive or motor related.

Nerve pain that patients may complain of include: cold to burning, shooting, tingling, or numbness. They may also complain of weakness.

CASE COMPONENT

Case Conclusion – Back Pain

Gary is very anxious and worried about his back. The GP realises that he will need a clear explanation of what’s going on.

 The GP explains why she thinks the X-ray wouldn’t be beneficial for Gary because of the limited information which is gained for his presentation, and the risks associated with the radiation in order to get the images.

She addresses Gary’s concerns, and explains that with support his back will improve, and the more he uses his back the sooner he can return to normal.

She discusses the options for management, which include:

· Being ‘back aware’ – making sure of correct posture for lifting and taking care with his work not to put unnecessary strain on his back. The GP also gives Gary some patient information leaflets from the ‘Web Mentor’ facility on Emis (the practice computer system) and a link to Backcare.org.

· Painkillers – this might include anti-inflammatories and paracetamol

· Physiotherapy

The GP discusses the options the patient has for painkillers. He is a bit wary of taking anything, but agrees he needs to take something but just as long as he isn’t doing any damage to his back. The GP reviews the electronic record during the consultation to check for allergies, intolerances and also renal and liver function tests, which are normal. She explains that the back needs to move for it to be healthy and that the painkillers will help him to do this, this doesn’t damage his back.

The GP suggests ibuprofen 400mg three times per day, for short term relief of the pain.

It may be useful at this point to review the chapter on prescribing analgesia in Prescribing Skills Handbook 2

Gary has never had any wheeze/asthma, and has taken ibupforen in the past without any stomach problems. Gary doesn’t suffer from heart burn. He is pleased that it’s not addictive. Gary is happy with this option. The GP outlines the possible risks of the medication, including possible stomach irritation and suggests that he should take this with food and advises him to to stop the medication and return for either an alternative medication or additional medication to protect his stomach if he does get any symptoms. He is advised to take it for a period of 2-3 weeks, and then review with the GP.

The GP explains that the main goal now is the get Gary back to normal so that he can continue with his normal activities, his job and his normal life and that she expects that this will happen. However, given his job involves heavy lifting, she suggests a fit note, with ‘amended duties’ to avoid heavy lifting.

Gary says he doesn’t feel that he is able to go back to any work at the moment, and he has already had 7 days off. The GP negotiates a period of a further week ‘signed off’ with a fit note marked ‘unable to work’. She arranges a review with him in 2-3 weeks, which Gary is happy with.

The GP makes sure that she gives Gary some safety netting advice. This is advice given to patients so that they know what to do if things change, and if there are any specific symptoms or signs which warrant them to do something particular.

When Gary returns 3 weeks later he is feeling much better. He had used ibuprofen for a few days,  and been swimming. He has returned to work and is being much more careful when lifting, and his employer has taken his needs into account and the company have brought in some lifting equipment.

When Gary returns 3 weeks later he is feeling much better. He had used ibuprofen for a few days,  and been swimming. He has returned to work and is being much more careful when lifting, and his employer has taken his needs into account and the company have brought in some lifting equipment.

Formative Assessment – Back Pain