FRCA Notes

Back Pain

This topic straddles both acute and chronic pain sections; the former often in the guise of lumbar radicular pain .

In this vein, the 2023 CRQ on the topic (74% pass rate) featured components on both red flags in back pain and definitions/management of radicular pain.

Resources

  • Back pain is the most prevalent musculoskeletal condition in the UK
  • It carries high healthcare costs and is a frequent cause of absence from work
  • The majority of arises due to:

    1. Discogenic back pain (30-40%)
      • E.g. due to disc herniation or degeneration
      • Can lead to neuropathic pain in the distribution of the compressed nerve root(s)

    2. Facet joint or sacro-iliac joint pain (30%)
      • E.g. due to osteoarthritis

    3. Other musculoskeletal conditions (30%)
      • E.g. due to muscle spasm, spondylosis/spondylolisthesis, scoliosis or spinal stenosis
      • Can lead to neuropathic pain, e.g. bilateral lower limb radiculopathy, spinal claudication

Sinister pathology

  • Sinister causes for low back pain are less common
  • Example aetiologies include:
    • Inflammatory arthropathies e.g. ankylosing spondylitis
    • Visceral pain e.g. renal calculi, ruptured abdominal aortic aneurysm
    • Epidural abscess or other infective causes
    • Epidural haematoma
    • Spinal cord compression due to malignancy
    • Acute vertebral fractures

  • One must use history, examination and relevant investigations to exclude sinister causes of back pain, or where there is concern over cauda equina syndrome


Patient factors Pain factors Associated symptoms Clinical signs
Age <16yrs or >50yrs Thoracic Fever/pyrexia Perianal sensory loss/paraesthesia
Previous malignancy Nocturnal Night sweats ↓ anal tone
Immunnosuppressed Assoc. w/ significant trauma Weight loss Hip / knee weakness
IVDU Bladder or bowel dysfunction Progressive and/or severe deficit
Concurrent medical illness Gait disturbance Point tenderness of vertebral body


  • Belief that pain is harmful or severely disabling
  • Fear avoidance behaviour inc. reduced activity levels
  • Expectation that passive treatment will be beneficial
  • Tendency to depression/low morale/social withdrawal
  • Social problems
  • Financial problems