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CSA Cases

Case 1





Topic Summary - Low back pain



This case assesses the candidate’s management of a common condition. The candidate must safely assess the patient with a targeted history and examination. The request for an X-Ray should prompt an exploration of the patients’ ideas, concerns and expectations. The candidate should explain the appropriate use of investigations with empathy for the patients concerns. A good candidate will reach a shared understanding of risk and management based on evidence for good practice.








Core knowledge:



Red Flags

         Must be assessed in ALL patients with back pain

·         backache in <20 years or > 55 years

·         history of cancer or immune suppression

·         non mechanical back pain (i.e. not related to movement)

o    inflammatory pain is

§  worse in the second half of the night or after waking.

§  associated with morning stiffness lasting more than 30 minutes.

§  is relieved by activity.

·         thoracic pain

·         systemic features (weight loss, night sweats, fever)

·         widespread neurological signs (disturbed micturition/anal tone, saddle anaesthesia, widespread progressive

motor weakness, gait problems)

·         progressive neurological signs

·         structural deformity or major trauma associated with backache

·         steroid use or drug abuse

·         severe nocturnal pain that disturbs sleep






A focused history and brief clinical exam are adequate to diagnose simple/‘non specific’ low back pain

·         No investigations are required for simple low back pain

·         Check that pain originates in the lower back (not hip/pelvis)

·         Assess for risk of long term pain/disability (Yellow Flags)

o    Misunderstanding of the cause of back pain.

o    The belief that pain and activity are harmful.

o    Sickness behaviours, such as extended rest.

o    Overprotective family

o    Social withdrawal, lack of support.

o    Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress.

o    Problems with claims for compensation or applications for social benefits.

o    Inappropriate expectations of treatment, such as low expectations of active participation in treatment.


In addition, for employees, assess for:

o         Prolonged time off work.

o         Problems or dissatisfaction at work.

o         Lack of support from the employer or co-workers.

o         Pessimistic expectations of ability to return to work.





·         Inspection for bony deformity

·         SLR for nerve root irritation

·         Sciatic stretch

·         Sensation/Power





The natural history

    50–80% recover completely in 4 weeks without treatment and 90% in 6 weeks.

    in 80% of cases no specific diagnosis is made;

    however, nearly 70% of patients who ever experience an episode will suffer three or more recurrences.




When to refer


Evidence of cauda equina syndrome or widespread neurological disorder (disturbed micturition/anal tone, saddle anaesthesia, widespread progressive motor weakness, gait problems).


     Red flag’ signs suggestive of serious pathology;

No referral

Simple backache and non-progressive nerve root entrapment should normally be managed within general practice, but referred if prolonged (not returned to normal activities in 3 months) and unresolved.




Tell the patient about the cause, treatment and self management – encourage positive thinking and self efficacy & correct any misunderstandings



·         Acute non-specific low back pain is a mechanical problem —caused by disturbance of function, not by serious structural damage.

·         Back pain is an everyday bodily symptom — it is not a disease in itself.

·         Acute non-specific low back pain settles in most people, but back pain does tend to recur at irregular intervals


Understanding the treatment

·         Pain control is routinely provided in the expectation that the pain will be temporary.

·         Recovery is helped by getting moving again and getting back to work as soon as possible.


Self care

·         A positive attitude is important in coping with the problem.

·         Medication can be taken to relieve the pain.

·         Staying physically active is likely to be beneficial.

·         Bed rest should not be prolonged any longer than is necessary.

·         Normal activities should be resumed as soon as possible. Because many normal postures and movements will stimulate some pain, resuming normal activities should be paced by conducting them at a reduced level or slower rate. The aim is to do a little more each day.

·         Keeping as active as possible and exercising regularly is important. Participating in a structured exercise programme should be considered (if available). Suitable exercise includes aerobic activities, movement instruction, muscle strengthening, postural control, and stretching.

·         Care should be taken when lifting and twisting.

·         A cold pack or local heat can relieve back pain.

·         A small firm cushion between the knees when sleeping on the side, or several firm pillows propping the knees up when lying on the back, may ease symptoms.

·         Return to work as soon as possible.

o    There is no need to wait for complete freedom from pain before returning to work.

o    Work adjustments can make an early return to work possible.

o    Returning to work helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.




·         Simple analgesia

·         Diazepam for muscle spasm if indicated


Follow up

If red flags present or if symptoms fail to improve within 6 weeks of onset





  • Exclude serious pathology (cauda equina, inflammatory arthritis)

  • Avoid investigation in acute simple low back pain

  • Reassure - 90% resolve in 6 weeks.

  • Analgesia, exercise, physiotherapy, education and spinal manipulation are equally effective.






CKS 2009

National Collaborating Centre for Primary Care 2009

NICE 2009

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