Back pain.

1. Back pain is very common and can be the result of a wide range of different conditions. A detailed history of the complaint often points towards the cause. Positional backache suggests a mechanical cause, unremitting pain may indicate malignancy or infection especially if accompanied by night sweats, whereas morning stiffness is more often the result of inflammation. 2. Examine the patient lying and standing as outlined. A general examination should also be performed if there is a history of weight loss, night sweats, or if the patient looks ill. 3. The vast majority of cases of backache are mechanical in origin. Plain x-rays are not normally contributory and should be avoided unless there are factors in the history and examination suggestive of infection or malignancy. 4. Patients with backache and sphincter disturbance and/or perineal anaesthesia require immediate hospital admission. 5. Analgesia and bed rest are the mainstays of treatment for acute backache of mechanical origin. Once there has been some improvement, physiotherapy can be beneficial. 6. Chronic back pain is present if the complaint lasts for more than 8 weeks. Investigations should include full blood count, ESR, calcium and alkaline phosphatase. The patient needs to be referred to a rheumatologist or orthopaedic surgeon for further assessment and possible imaging studies. If no cause other than mechanical dysfunction is found the patient should be assessed by a physiotherapist and taught back care.