Most back pain is benign but some isn’t. Five or six times a year I treat a patient who’s progressed from backache to paraplegia over a few months, via discitis or cancer or cord/cauda equina compression, generally while under the not-watchful-enough care of one or more family doctors. These patients have often been seen at several clinics or even hospitalized more than once at teaching hospitals. That’s tough to defend in court. My experience is not unique; these issues are recognized around the world and have even made their way into spine care textbooks.

Incidence

Low back pain is a very common complaint in modern society, prevalence being roughly 40% in accumulated studies from around the world. Most of those affected don’t complain about it, don’t need any treatment for it and either live with it or get over it spontaneously. I’m a good example of that: I take a 650 mg coated ASA every morning for my own backache and that works great for a 50-year-old spine that earns a living doing 4- and 5-hour spine operations wearing a 30-pound lead fluoroscopy jacket several days a week.

Disability

In fact, 10% of us will be transiently disabled by it at some point in our lives — but even acute disabling low back pain will resolve spontaneously in the majority, 90% or more resolving completely within days or weeks. Again, I’m a good example of that myself. Ten years ago I rode a roller coaster and was too excited (scared) to sit down and brace myself properly when it started. I heard a big “crunch” at the bottom of the first big dip. I did fine at first, but three days later when I got out of bed, my knees just buckled under me and down I went. I stayed down for about 10 minutes and then was able to get up slowly and after four achy stiff days I was just about fine again — except I really like that ASA!

Pathology and natural history

Imaging pathology is very common and usually false (positive), meaning that it’s not a source of symptoms. Odds are 50/50 that a lumbar-asymptomatic patient from your office today will have major degenerative abnormalities in any imaging study you ask for, from x-rays to MRI, that don’t hurt one bit. That’s why we’ve all been taught that acute spine imaging is useless and generally it is. That bone spur or degenerated disc or spondylolisthesis seen in your patient’s x-ray was almost certainly there last week too, when the patient felt fine!

Even acute structural spine disease gets better in most cases by ‘hand of God,’ like I did after the rollercoaster episode. Acute sciatica from disc hernia resolves within weeks in 60-75% of cases, even with dropfoot (which of itself is not an emergency and not necessarily an indication for acute surgery). Seventy percent of acute symptoms from spinal stenosis or spondylolisthesis resolve within a few months, and even insufficiency fractures heal 70% of the time to become asymptomatic within three to four months.

Cost

Spine care is costly, but we know that a small minority (10%) of patients who have recurrent or chronic pain generate 90% of the cost. Most of these have nonspecific pain, usually major secondary gains and a big behavioural component to their pain, and honestly most of the treatment applied here has been shown to be ineffective. The elite flagship Cochrane collaboration meta-analysis website (www.cochrane.org) uniformly reports little long-term benefit from virtually all back care treatments with the probable exception of well-done cognitive behavioural therapy (CBT) — which doesn’t mean that every chronic back pain patient is a hypochondriac, it just means that many patients benefit from therapeutic assistance with understanding and coping mechanisms.

So, most cases get better without intervention, but some don’t. There are several very real structural spine pathologies that can benefit greatly from acute diagnosis and care. Things like discitis and metastatic lesions and chronic cauda equina syndrome are population-rare but all too common in a referral spine practice like mine and the history is almost always one of tragically delayed diagnosis and compromised outcomes — including paraplegia and death — from missed opportunies for early care. There are relatively few spine surgeons out there but lots of primary caregivers, so the burden of screening naturally falls on general and family practitioners.

A lot can be achieved by remembering the usual profile of benign back pain, and also by knowing and recognizing some red flags for low back pain, which can be identified by asking just a few simple questions.

The profile of benign back pain

Benign chronic or recurrent back pain generally presents around the 40s, most often in the lumbar region of males who do heavy physical work and who have a history of work injuries or other trauma. The pain episodes are generally of stable or consistent intensity, it gets better with rest/lying down (it’s “mechanical”), there are no neurological or constitutional symptoms and while there may be work and activities disability, there is almost never a locomotor disability.

The red flags

So, one red flag is a history of onset at age either > 50 or < 20 years. A second is the absence of a trauma/injuries history (i.e. the spontaneous onset of pain). The third red flag is pain located outside the low back region where cancers and fractures and infections are actually quite rare.

A history of significant trauma should be a fourth red flag for fracture but too often isn’t. Unbelievably, every year I see people who crash their cars or fall off ladders and don’t get x-rays done for months.

Any patient with a history of cancer (there’s red flag number five) who presents with new-onset low back pain should be considered as metastatic until proven otherwise. And anybody with a history or high risk of immunosuppression — identified AIDS or HIV, recreational needle drug users, taking steroids or immunosuppressants — has a discitis until proven otherwise (that’s red flag number six).

Another red flag frequently missed (number seven) is history of neurological symptoms, like numbness/tingling or claudication (i.e. “I can only walk a short distance or time before my back pain forces me to stop”). Don’t depend on concrete neurological findings on physical exam — such symptoms are often delayed and by then it’s often too late. The history is enough to alert you, but you must ask for it. Incredibly, just about every year I see a patient who gets to the point where they’re crawling around the house on hands and knees from pain, but because they don’t have a weak ankle or numb toe they don’t get referred.

Constitutionality is red flag number eight — the backache patient who is losing weight or having fevers should be taken very seriously indeed. Night pain is less of a concern. We used to think that pain at night was a red flag but it’s been conclusively shown that’s not so. Pain that isn’t mechanical, that persists even when lying down, can be red flag number nine.

The final red flag, number ten, is a history of rapidly escalating pain. These patients with chronic benign back pain often have a slowly escalating analgesic requirement as their livers respond to the stress challenge of metabolizing their prescribed drugs and they become habituated, but that evolves over months and years. When your patient needs more and more drugs daily or weekly, there’s often something very bad going on.

 

What to ask?

You can screen your patient in just a few seconds.

How old are you? (1st red flag)

Where’s the pain? (3rd)

How did it start, with no injury (2nd) or serious trauma? (4th)

Any history of cancer (5th), immune suppression or recreational drug use? (6th)

Neurological symptoms? (7th)

Fever or weight loss? (8th)

Does it get better when you lie down, or not? (9th)

Is it pretty stable in intensity or is it worse than it was last week? (10th)

 

What if screening is positive?

I would say that patients whose answers raise red flags should be referred immediately to a qualified spine surgeon — and they should — but that’s not practical in the real Canada because there just aren’t enough spine surgeons around to refer to.

A little physical exam on your part can help. Finding a tender deformity or neurological deficit may get your referral surgeon excited and bump your patient up the waiting list. Likewise, get an x-ray of the painful region right away (not just a standard lumbar film, which would be useless for a thoracolumbar fracture or thoracic metastatsis, but imaging focused on the area of pain). If it’s positive, again that can speed your patient to accelerated care.

If not, then order an MRI right away. Sure, in most of Canada it’ll take a few weeks to get it, but there’s no harm in getting your patient in line fast. Maybe it’s just benign backache and they’ll get better while waiting for the scan. Then no harm has been done and you can cancel the scan. But if it’s not benign backache, if there’s real trouble in there, the radiologist may page a specialist right from the scanner.

If you can’t get your patient accepted by your referral spine surgeon after all this, then explain your concerns to the patient and just send them to the emergency room of your referral spine centre. This is not a “dump,” it’s optimized and responsible patient care in a system where access is known to be limited. Odds are that there’s a spine physician of some sort on call, and even if not, this will generally get the patient referred into the local spinologist’s next clinic. Sneaky but it works!