Back Pain in the Older Patient

Back pain is a very common problem for general practice patients, and most of the time it does not have a sinister cause. However, at recent serious case reviews there have been a number of cases where back pain in older patients has been the first presentation of more sinister diagnoses.

When assessing any patient with back pain the European Back Pain guidelines recommended an initial assessment of "red flags". Red flags are signs in addition to low back pain. These include:

• Age of onset less than 20 years or more than 55 years

• Recent history of violent trauma

• Constant progressive, non-mechanical pain (no relief with bed rest)

• Thoracic pain

• Past medical history of malignant tumour

• Prolonged use of corticosteroids

• Drug abuse, immunosuppression, HIV

• Systemically unwell

• Unexplained weight loss

• Widespread neurological symptoms (including cauda equina syndrome)

• Structural deformity

• Fever

In the case reviews there were red flags which had been discounted by the GPs, including age over 55. Any patient with red flag symptoms or signs should have further investigations including blood tests and imaging to look for possible sinister causes of back pain such as infection, malignancy, osteoporotic fracture, or rheumatologic disease.

The guidelines also advise reassessment at follow-up visits after 1 week if severe pain does not subside, after 3 weeks if the symptoms are not diminishing, and after 6 weeks if there is still disability or if there is no progress in function, or if pain does not decline.

The LMC suggests that practices may wish to use these guidelines to help clinicians with the assessment of patients with back pain.