Question

A 45-year-old manual labourer comes to seek help for his low back pain.
How will you approach a patient with low back pain?

Hint:

For patients with low back pain, start with conservative management, including physical therapy and pain relief, unless red flags or serious conditions are suspected.

Answer 1

Step 1: Detailed History and Examination.
The first step in evaluating low back pain is taking a thorough history. This includes:
- Duration, intensity, and pattern of pain.
- Factors that exacerbate or relieve the pain.
- Any history of trauma, heavy lifting, or unusual physical activity.
- Associated symptoms such as numbness, tingling, or weakness.
Physical examination should include inspection of posture, palpation of the spine, and testing of range of motion. Neurological examination may be necessary to rule out nerve involvement.

Step 2: Assess for Red Flags.
It is important to look for red flags that indicate serious underlying conditions, such as:
- Weight loss, fever, or night pain (suggesting possible infection or cancer).
- Bladder or bowel dysfunction (suggesting cauda equina syndrome).
- History of trauma or osteoporosis (increasing the likelihood of fracture).

Step 3: Diagnostic Investigations.
For most cases of low back pain, imaging is not immediately required unless red flags are present or the pain persists beyond a few weeks. If necessary, imaging techniques such as X-rays, MRI, or CT scans may be used to assess for fractures, disc herniation, or tumors. Blood tests may be used if infection or inflammatory conditions are suspected.

Step 4: Management Plan.
Treatment for low back pain depends on the underlying cause. Most cases are managed conservatively with:
- Analgesics (NSAIDs, acetaminophen) for pain relief.
- Physical therapy to improve mobility and strengthen the muscles supporting the back.
- Lifestyle modifications, including ergonomic changes and exercise.
In cases of mechanical pain, rest and gentle stretching may be helpful. For more severe conditions, such as herniated discs, surgical intervention may be required.

Step 5: Conclusion.
The management of low back pain requires a comprehensive approach, starting with a thorough history and examination, followed by diagnostic investigations if necessary. Conservative treatment is effective in most cases, but surgery may be needed for more severe or persistent cases.