Intended for healthcare professionals

Clinical Review

Diagnosis and treatment of low back pain

BMJ 2006; 332 doi: (Published 15 June 2006) Cite this as: BMJ 2006;332:1430

Back Pain- Think of Tuberculosis

We read with interest the clinical review on low back pain by Koes et
al identifying some red flags which may indicate underlying spinal
pathology in individuals presenting with back pain. (1) We are however
concerned that the authors advise referral for imaging only in the
presence of these red flags.

We recently completed a retrospective study of patients with spinal
tuberculosis (TB) at Ealing hospital. Of 29 adult patients diagnosed
between 2002 and 2005, 23 (80%) were aged between 20 and 50 years (mean
age 38.5 years). All were originally from the Indian subcontinent or
Africa. Most patients had been in the UK for more than 5 years (range 1-26
years). None were HIV positive, gave a history of carcinoma or steroid
use. Only 4 (14%) had a history of previous tuberculosis or close TB
Almost all of the patients gave a history of constitutional symptoms
(fever, night sweats, weight loss or loss of appetite). Lumbar and
cervical back pain was seen more commonly than thoracic. The ESR was
greater than 35mm/hr on presentation in almost all of them (96%).
Many of the patients had repeatedly sought healthcare advice from their
general practitioners or the accident and emergency department before
diagnosis was made.

A delay in the diagnosis of tuberculosis exposes young patients with
a treatable condition to the risk of permanent disability. Non-pulmonary
tuberculosis accounts for around 40% of all TB notifications in the UK.
(2) The incidence of tuberculosis in London has reached 48/100,000 and
in areas such as Ealing with a large immigrant population, the rates are
as high as 82/100,000. (3) Spinal TB is, therefore, a diagnosis that needs
to be considered early by attending physicians.

The red flags mentioned in the review could not have been used to
identify most of these patients. We therefore suggest that patients from
countries with high TB prevalence presenting with back pain in association
with constitutional symptoms and a high ESR should be investigated to
exclude tuberculosis. In the context of a normal spinal X-ray and a high
clinical suspicion, further cross-sectional imaging may be warranted. This
is irrespective of their age or duration of stay in the UK.

1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low
back pain. Bmj 2006;332(7555):1430-4.

2. Health Protection Agency. Annual report on tuberculosis cases
reported in England, Wales and Northern Ireland in 2003;

3. Health Protection Agency. London Surveillance Bulletin. May 2006

Competing interests:
None declared

Competing interests: No competing interests

09 July 2006
Lavanya Diwakar
Research Fellow in Infectious Diseases
Sarah Logan, Nadia Ghaffar, Andrew Hare, William Lynn, Steve Ash
Ealing Hospital , Uxbridge Road, Middlesex, UB1 3HW