From
Dr. Amr Moursi
Clinical Approach to Back Pain: From Diagnosis to Treatment Strategies (4th Medical student)
With Dr. Amr Moursi
Chapter 1 of 6 · Fundamentals
Pain mechanisms
Introduction and Mechanisms of Back Pain
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most people will experience back pain at some point in their life, making it one of the most common symptoms.
The most common mechanism of back pain is muscle spasm or muscle strain, occurring with heavy loads or trauma to the back muscles.
Disc degeneration primarily causes leg pain, not back pain, but is usually associated with facet joint hypertrophy, arthritis, inflammation, and loss of disc height that contribute indirectly to back pain.
Red flag signs in history for serious back pain include age less than 20 or more than 55 with persisting low back pain.
History of malignancy, weight loss, immunosuppression, night pain not improved with rest, and recent trauma are red flag signs suggesting serious pathology.
Cord compression presents with upper motor neuron signs: bilateral lower limb weakness, spasticity, hyperreflexia, and a sensory level corresponding to the compressed cord level.
Cauda equina syndrome presents with the triad of saddle anesthesia (perianal numbness or decreased sensation), bladder/bowel dysfunction causing urine retention and overflow incontinence, and sexual dysfunction.
Overflow incontinence in cauda equina occurs when the patient is unable to feel the need to void, goes into retention, and then becomes incontinent when bladder capacity is exceeded; bladder scan shows high volume (at least above 200 mL).
Urge incontinence is different from overflow incontinence: the patient feels the need to void, knows they need to go, but cannot hold urine until reaching the toilet due to urethral sphincter weakness; this is not associated with cauda equina.
Cauda equina syndrome also presents with weakness, hyporeflexia in the lower limbs, and sometimes bilateral sciatica.
X-ray is rarely needed for back pain evaluation and has low clinical value regarding serious back pain, though sometimes done in A&E.
CT scan is appropriate when evaluating bony lesions like fractured spine or metastatic spine deposits, and serves as an alternative when MRI is contraindicated.
MRI is the gold standard for back pain imaging, allowing visualization of soft tissue including disc herniation, epidural abscess, and tumors.
According to NICE guidelines, first-line non-pharmacological interventions for back pain include self-management through patient education, exercise (stretching and core muscle strengthening), manual therapies like massage, and psychological therapy including CBT.
Mental health and well-being significantly influence how patients perceive back pain; conditions like fibromyalgia are particularly influenced by mental health, making CBT and psychological treatment effective for chronic back pain.
According to NICE guidelines, first-line pharmacological treatment for low back pain is non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ibuprofen, with proton pump inhibitors to prevent gastritis.
Second-line pharmacological treatment for low back pain is weak opioids like oxycodone or co-codamol, not paracetamol.
Paracetamol is not routinely recommended and not recommended as standalone treatment for low back pain according to NICE guidelines.
Antidepressants and antiepileptics are not recommended for mechanical low back pain according to NICE guidelines.
For neuropathic leg pain, first-line treatment options include amitriptyline (tricyclic antidepressant) at 10-25 mg at night, which improves neuropathic pain, helps sleep, and improves mental health.
Duloxetine is another option for neuropathic pain and can be used alone or in combination with amitriptyline.
Pregabalin and gabapentin are treatment options for neuropathic pain; start with a single drug at low dose and increase gradually to allow patient tolerance of side effects, tailoring dose to individual patient response.
Spinal injection (combination of steroids and local anesthetic) is a minimally invasive intervention injected under fluoroscopy and X-ray guidance directly to the nerve for radicular leg pain, not for back pain.
Corticosteroids in spinal injections decrease inflammation around the nerve, temporarily reducing pain impulses before other treatments take effect.
Radiofrequency denervation should be considered for chronic low back pain in patients showing positive response to medial branch block; patient selection must be very selective.
Epidural injection can be used for bilateral leg pain to improve radicular symptoms.
Spinal decompression and discectomy are used for large disc herniation compressing nerves that do not respond to medical treatment or causing cauda equina syndrome requiring urgent/immediate surgery.
In spinal decompression surgery, part of the herniated disc is removed and part of the bony canal is removed to widen the canal.
Spinal fusion is indicated for fractured spine with instability; not all fractured spines need fusion—only certain types of instability require fixation, while other cases may be managed with bracing alone.
Spinal decompression and discectomy primarily address leg pain, not back pain, though back pain may improve indirectly due to reduction of associated pathology like facet degeneration and ligamentum hypertrophy.
Patients should be counseled that lumbar decompression will primarily address leg pain; there is a chance back pain may improve, but additional non-pharmacological and pharmacological treatment for back pain may still be needed.
Back pain that does not improve with exercise typically indicates mechanical back pain; improvement with stretching or physical exercise relieves concern about serious pathology.
The classic presentation of cauda equina syndrome is bilateral sciatica, saddle anesthesia, and bladder dysfunction with urinary retention.
Hyperreflexia below the level of the lesion is the most characteristic sign of spinal cord compression, distinguishing it from cauda equina syndrome (which presents with hyporeflexia).
Imaging studies of the spine should be considered when red flags suggest serious pathology, not routinely for all back pain or based on patient request.