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Management of back and neck pain

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Back pain is a common presenting complaint in primary care and is also a problem in terms of health outcomes. Consequently, guidelines have evolved to help guide healthcare professionals on appropriate management of patients with back pain. This resource consisting of 10 assessment questions tests knowledge of the management of typical clinical issues such as lower back pain and neck pain. Complete the resource to obtain a certificate for 1 hr of continuous professional development to include in your annual portfolio.

On completion of this resource the user should be able to:

Understand the diagnosis of chronic lower back pain and whiplash.

Appreciate and implement the treatment strategies according to published guidance.

Appreciate the referral criteria for such disorders.

Guidelines for the management of whiplash disorders

Back pain is a common presenting complaint in primary care and is also a problem in terms of health outcomes. Consequently, guidelines have evolved to help guide the healthcare professional on appropriate management. This module consisting of 10 assessment questions tests knowledge of the management of typical clinical issues such as lower back pain and neck pain. Complete the module to obtain a certificate for 1 hr of continuous professional development to include in your annual portfolio.

Primary Care

A 35 year old carpenter attends the surgery complaining of 6 weeks of low back pain. He has no leg pain, but has not been to work for 4 weeks. No specific abnormality is found on examination. Which of the following should be advised?

Guidance would suggest that this man with mild back pain should be prescribed simple analgesia such as paracetamol or ibuprofen, and also advised to continue modest exercises. Doctors used to prescribe bed rest for patients with back pain, however most doctors now agree that keeping active is important in the recovery process. Physiotherapists may give individual advice to this patient regarding which exercises he should or shouldn't do. Hot or cold compresses can also be used, which can either be bought at a pharmacy, or simply use a bag of frozen peas.

http://www.nhs.uk/Conditions/Back-pain/Pages/Introduction.aspx

Question 1

A 62 year old builder presents with lower back pain of 8 weeks duration. He has continued to work and has been taking regular paracetamol with minimal relief. The next option for symptom relief would be?

This man has persistent lower back pain despite regular paracetamol analgesia and should now try Non-steroidal anti-inflammatory drugs such as Ibuprofen according to the WHO's analgesic ladder. This is a stepwise approach to the management of pain. Step 1 would be simple analgesia such as paracetamol, and ibuprofen. Step 2 includes weak opioids such as tramadol and codeine. If further analgesia is required, step 3 is the addition of strong opioids such as morphine. Therefore, this patient needs to try ibuprofen to see if that helps with his pain. However, regular use of ibuprofen can cause irritation to the stomach, and cause gastric ulcers. Therefore, the recommendation would be to take this with a proton pump inhibitor such as omeprazole.

http://www.paincommunitycentre.org/article/who-analgesic-ladder-0

http://www.patient.co.uk/doctor/Peptic-Ulcer-Disease.htm

Question 2

A 32 year old female complains of a 4 week history of lower back pain. In the past week she has had bilateral leg pain and this morning was incontinent of urine. Which of the following would be the most appropriate option for this patient?

This woman has worrying neurological signs suggestive of cauda equina syndrome. The cauda equina is the nerve roots formed where the spinal cord ends. When these nerves are compressed, patients present with symptoms such as leg pain, perineal/saddle sensory disturbances and incontinence. This is a medical emergency, and immediate referral for specialist assessment must be made to prevent permanent neurological damage.

http://www.patient.co.uk/doctor/Cauda-Equina-Syndrome.htm

Question 3

A 67 year old man presents with a 10 week history of severe back pain which keeps him awake at night, is now complaining of numbness in both legs. He is a heavy smoker and has a history of lung cancer treated 5 years ago. Which of the following is the most likely diagnosis?

This man has a history of lung cancer which is the most common cancer to metastasis to the spine (others that metastasise to bone include breast and GI tract tumours) The most likely diagnosis therefore would be a metastasis of this tumour to the lumbar vertebral region producing pain with infiltration/potential vertebral collapse.
There is no treatment that will improve the life expectancy for this presentation, treatment is therefore palliative. The patient should be referred to palliative care to look after his pain management.

http://emedicine.medscape.com/article/1157987-overview#a0104

Question 4

A 55 year old male who is a cab driver re-attends clinic as you have been treating him over the last two months for lower back pain. There are no specific features of note on examination but the pain hasn't responded to paracetamol and exercises. Which, if any of the following would you recommend?

The patient hasn't responded to paracetamol and so an NSAID such as ibuprofen should be added to his treatment, according to the NICE guidelines. This man should also be co prescribed a Proton Pump Inhibitor such as omeprazole due to the irritation caused by NSAIDs. In the absence of any suspicious features, an X-ray is considered unnecessary.

http://www.nice.org.uk/nicemedia/live/11887/44334/44334.pdf

Question 5

A 42 year old male has an 6 week history of shooting pain radiating from the left buttock to the left foot. He has no neurological deficit and has been taking paracetamol and ibuprofen but continues to have pain. Which of the following is the most appropriate approach to managing this patient?

This man is presenting with sciatica, which is pain coming from the nerve root. This means that a nerve coming out from the spinal cord is irritated or pressed on, causing pain along the course of the nerve. Patients typically feel pain down a leg, pins and needles, numbness. The most appropriate approach to managing this patient's pain in the absence of any sinister features suggestive of compression would be referral for physio review and appropriate exercise programme. It is important to keep physically active, and a physiotherapist can give advice on suitable exercises.

http://www.nhs.uk/Conditions/Sciatica/Pages/Treatment.aspx

Question 6

A 55 year old patient has been treated for chronic aching lower back pain of 3 months duration. He has had persistent problems despite the use of paracetamol, ibruprofen and an exercise programme. Which of the following agents should next be offered to treat his on-going pain?

The most appropriate approach to treat this man who continues to have low back pain despite exercise programmes and analgesia is a tricyclic antidepressant as suggested by guidance. It is started with a low dose, and gradually increased to a maximum dose. If this does not work, stronger opioids for short term use may then be considered.



http://www.nhs.uk/Conditions/Back-pain/Pages/Treatment.aspx

Question 7

A 35 year old man attends clinic a day or so after he had a low velocity road traffic accident where his car was hit from behind by another car at approximately 20mph. He was wearing a seatbelt. He is complaining of neck pain, dull headache and tingling in the neck and shoulders. Which of the following is the most appropriate approach to his management?

This patient presents with features of whiplash, which is a term that describes a neck injury after the sudden movement of the head. Ligaments are damaged in the neck, causing pain, stiffness and loss of movement. This can take months to heal. Headaches, muscle spasms, and shoulder pain are also possible symptoms, as seen with this man. With regard to this injury 

, the most appropriate approach to management is to offer adequate analgesia with paracetamol/NSAIDs but avoid immobility. Patients should be advised that resting the neck will prolong the symptoms, and delay recovery, and bed rest and soft collars should be avoided.

http://www.nhs.uk/Conditions/Whiplash/Pages/Introduction.aspx

Question 8

A 53 year old man attends clinic with a 7 week history of low back pain. Which of the following would be a symptom that would suggest a serious underlying cause for his problems?

When a patient presents with back pain it is important to ask for the red flag symptoms. These are symptoms that suggest an underlying cause which require immediate medical attention. An unexplained weight loss, fever or neurological deficits are 

s that should signal a potentially serious cause for the low back pain such as malignancy or infection.

http://www.nhs.uk/Conditions/Back-pain/Pages/Symptoms.aspx

Question 9

A 45 year old woman was involved in a low impact car shunt approximately 1 week ago. She now attends clinic complaining of whiplash. Which of the following is a yellow flag sign indicating psychological factors that would impede a recovery?

 (page 7) features that are considered to be affecting the patients response to treatment. It is important to recognise these factors as early intervention, counselling and guided treatment may prove to be essential in preventing poorer outcome. Female sex, older age, more severe symptoms, headache with pain radiating to arms, multiple initial symptoms, being unemployed and having dependents are all yellow flag factors.

http://www.whiplashprevention.org/SiteCollectionDocuments/Research%20Articles/Medical%20-%20Whiplash/GuidelinesDiagnosingWhiplash.pdf

Management of back and neck pain

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