Primary care

Chronic low back pain

Jo Samanta, clinical research assistant, Julia Kendall, general practice clinical assistant, Ash Samanta, consultant rheumatologist. 

Department of Rheumatology, Leicester Royal Infirmary, Leicester LE1 5WW

Correspondence to: A Samanta ash.samanta{at}uhl-tr.nhs.uk

A 40 year old man presents with a two year history of chronic low back pain. For the past week he has had an exacerbation of his symptoms and intermittent pain radiating down his right leg.

	What issues you should cover

Top What issues you should... What you should do

Symptoms Discuss the likely causes. Show him a diagram or model of the lumbar spine indicating the vertebrae, discs, and nerve roots. Explain that his leg pain is due to irritation of the nerve roots and that effective treatment should alleviate both his back pain and his leg pain.

"Red flag" and "yellow flag" signs Red flags are possible indicators of serious spinal pathology: Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years Yellow flags are pyschosocial factors shown to be indicative of long term chronicity and disability: A negative attitude that back pain is harmful or potentially severely disabling Fear avoidance behaviour and reduced activity levels An expectation that passive, rather than active, treatment will be beneficial A tendency to depression, low morale, and social withdrawal Social or financial problems

• Any recent trauma, which may raise the possibility of a fracture
• "Red flag" signs (see box), which may indicate serious spinal pathology
• "Yellow flag" signs, which are factors recognised as having an influence on long term disease outcomes and which may cloud assessment and treatment.

	What you should do

Top What issues you should... What you should do

• If red flag signs are present refer him to a specialist for further evaluation and advise him to rest and to avoid physical activity until then. If no red flags are present, reassure him that there are no indications of serious spinal pathology and that a full recovery from this acute episode is likely. Nerve root pain is not itself a cause for alarm, and conservative treatment (which may take 6-8 weeks) should be effective.
• Managing symptoms with paracetamol or non-steroidal anti-inflammatory drugs is usually effective. Check for contraindications and offer practical advice on using the drugs. Assess whether concomitant muscle relaxants and simple analgesia are needed.
• Consider whether adjunct management with manipulation of the lumbar spine or physiotherapy is indicated. Applying cold compresses or warm pads may relieve symptoms.
• Advise him to resume normal activities as soon as possible and to "let pain be his guide" as to the appropriate level of activity. Explain that this will help to relieve symptoms and reduce the risk of chronic disability.
• Encourage a prompt return to workalthough manual handling may be an issue, and training in lifting may be advisable. Discuss whether you might need to liaise with his workplace.
• If yellow flags are present, assess him for signs of depression or unhappiness at work or home. This may promote "illness behaviour" and should be treated accordingly.
• Emphasise and encourage positive lifestyle changes such as maintenance of physical condition, avoidance of smoking, and weight control.
• Consider giving him a copy of The Back Book, an evidence based patient information booklet available from the Stationery Office.
• Ask him to return in six weeks if his symptoms haven't improved.

	Footnotes

The series is edited by general practitioners Ann McPherson and Deborah Waller

The BMJ welcomes contributions from general practitioners to the series This is part of a series of occasional articles on common problems in primary care