Back Pain

BMJ Clinical Reviews either hit the spot or leave me cold. Koes et al on "Diagnosis and Treatment of Low Back Pain" hit the spot. Whilst the tenor of the article was emphasising the GP things that I already do - encourage exercise and early mobilisation - it was the proportion of people with serious underlying disease (in an American study) that caught my eye:

• 4% have a compression fracture
• 3% spondolisthesis
• 0.7% a tumour or metastasis
• 0.3% ankylosing spondylitis
• 0.01% and infection

this really caught my eye. In the last 3 months I have seen a dozen or so people with back pain, surely I am missing something in 1 of them. The article reminded me that I should watch for red flags:

• age at onset <20>55 yrs
• non mechanical pain
• thoracic pain
• pmh of cancer, steroids or HIV
• feeling unwell
• weight loss
• widespread neurological symptoms
• structural spinal deformity

but it didn't help with what to do if there was a red flag flying. Imaging should be carried out where there are red flag signs, perhaps some other advice on investigations could have been included.