Sinister Causes of Back Pain

Most doctors are fearful of missing a sinister cause of back pain. So, it is natural that we become conservative and defensive in our practices. In truth though, sinister causes will affect 0.1% or less of patients with back pain in a primary care setting.

Of course, no one wants to miss these, so it’s a question of sorting the wheat from the chaff.

There are no definitive diagnostic methods, and it is impossible to MRI every patient with back pain.

It is also important to be mindful of people who present with non-specific back pain. As has been researched and reported by Professor Chris Maher, investigations such as an MRI can entrench their psycho-social pain and worsen their condition.

The fact of an MRI confirming their fears and the pain can become medicalised.

This can be irrespective of the outcome of the MRI.

“Most people with acute back pain, about 90 per cent, have non-specific back pain. If you send them off for imaging, about a third will come back with something found.

Patients then focused on the imaging results and could become quite disabled by them.” ^[1]

Guidelines for diagnosis

• Medical history is important.

1. If the back pain has been for longer than 12 months and the patient has oscillated in and out of pain then it cannot be sinister.
2. If the pain is slowly increasing continuously, without pauses during the day; and the patient cannot find a comfortable position, then there is a possibility of inflammatory disease, malignancy, or infection.
3. Age of patient comes into play. Instances of cancer increase with age. If your patient is 60+ years old then the probability of cancer increases.
4. Neurological symptoms, especially if they persist, are a significant factor and deserve further investigation in all cases.
5. Previous history of cancer or infection is the most powerful indicator.

• Classic ‘Red flag’ symptoms are too generalised and non-specific.

• Physical examinations other than if the pain is highly localised, or neurological, are of little value.

Further examination

If the history is concerning then investigate further with an MRI.

If you are suspicious, a CRP blood test will identify if there is an infection.

Otherwise send the patient home. Prescribe a simple analgesic, like paracetamol, and ask them to return in 4 weeks.

Upon their return if the pain persists or worsens, then investigate further with an MRI and refer them to a spinal surgeon for a more extensive diagnosis.

Although this might sound obvious please specify that the MRI is of the part of the body that hurts.

At least three in ten of the MRIs or CT scans sent to me need to be retaken as they are not specific enough.

^[1] as reported https://www.smh.com.au/lifestyle/the-truth-about-back pain-20131010-2vah5.html

Please also view the recording of my webinar on Sinister Causes of Back Pain here.

And as always if you have any questions about a patient, please feel free to call me on 02 9650 4893. I will return your call and discuss how we can help.

You can also reach me via ralphstanford@powspine.com.au.

Further Resources for Referrers include:

• Spinal Fusion surgery
• Foot Drop
• Why I only operate when it makes a difference to my patient's quality of life
• The limited role of cortisone injections for spinal conditions
• Cervical myelopathy – a disease of the spinal cord that may pass unnoticed
• Cervical Radiculopathy – shooting pains from the neck
• Back pain and how to manage it

Dr Ralph Stanford is a spinal surgeon with over 20 years’ experience. He is adept in all surgical approaches to successfully treat his patients.

As a teacher Dr Ralph Stanford is Conjoint Senior Lecturer at the UNSW; Supervisor of Training for Orthopaedic Trainees, Prince of Wales Hospital; and Education Secretary for the Spine Society of Australia.

As a researcher and scientist, he is a well-published author and Honorary Senior Scientist at Neuroscience Research Australia (NeuRA). He is also a current member of Spinal PFET. 

Posted 25 March 2022