Back Pain (lower)
Lower back pain is a common musculoskeletal condition characterized by pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without radiating leg pain.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Mechanical / non-specific LBP | Acute onset, no radiation below knee, relieved by rest, localised tenderness, no neurological deficit [5] | 「痛有冇落腳？瞓低會唔會好啲？」(No radiation, rest helps) | ~70% |
| Lumbar spondylosis / OA spine | Older patient, chronic, stiffness after rest, no inflammatory features | 「坐耐或者起身嗰陣僵硬嗎？」 | ~20% | |
| Lumbar disc herniation with sciatica | Dermatomal leg pain below knee, ↑ by cough/sneeze, +ve SLR 30–70° [1][6] | 「痛有冇去到腳趾？咳嗽會唔會痛啲？」 | ~10% | |
| Serious Not To Miss | Osteoporotic compression fracture | Post-menopausal woman, sudden onset after trivial fall, midline tenderness, height loss [7] | 「有冇矮咗？有冇跌親之後先痛？」 | ~3% |
| Spinal malignancy / metastasis | Age > 50, hx of cancer, unexplained weight loss, night pain, no relief with rest | 「以前有冇癌症？有冇瘦咗？夜晚瞓唔着痛？」 | ~1% | |
| Spinal infection (TB, epidural abscess) | Fever, IVDU, immunosuppression, night sweats, localised severe tenderness | 「有冇發燒？有冇去過高危地方？」 | < 1% | |
| Cauda equina syndrome | Urinary retention/incontinence, saddle anaesthesia, bilateral leg weakness [4] | 「有冇去唔到小便、或者下面麻痺？」→ Urgent MRI, decompression < 48h | < 1% | |
| Pitfalls | Spinal stenosis (neurogenic claudication) | Bilateral leg pain/weakness on walking, relief by sitting/flexion, variable claudication distance [2] | 「行路行耐會唔會腳痺？坐低會唔會好返？」 | ~5% |
| Sacroiliac joint dysfunction | Unilateral buttock pain, +ve FABER test, no radiation below knee | 「痛響屁股嗰邊多啲？」 | ~4% | |
| Referred pain (AAA, renal colic, pancreatitis, gynae) | Abdominal symptoms, colicky/pulsatile, no spinal tenderness | 「有冇肚痛、嘔？月經正唔正常？」 | ~2% | |
| Masquerades | Psychosocial stress / work pressure / fear of serious disease | Excessive worry, functional impairment disproportionate to findings | 「你最擔心係咩嚟㗎？」 | ~20% |
| Depression | Chronic diffuse pain, poor sleep, low mood, anhedonia | 「心情點呀？有冇覺得冇乜嘢開心？」 | ~10% | |
| Ankylosing spondylitis | Young male, inflammatory back pain pattern, limited spinal mobility, +ve HLA-B27 [3] | 「朝早僵硬超過半個鐘？郁吓會好啲？」 | ~2% |
GC 226 High-Yield: The GC 226 lecture series emphasises the physical examination of the lumbar spine (Part B), investigations (Part C), and specific pathologies (Part E) including disc herniation, spinal stenosis, spondylolisthesis, and red flag screening [1]. Inflammatory vs mechanical back pain distinction is a classic exam discriminator [5].
Back Pain (Lower) — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好，我係X醫生，今日由我同你傾吓，方唔方便㗎？」(Hello, I'm Dr X, I'll be chatting with you today, is that OK?) | Friendly opening; establishes rapport; interpersonal marks |
| 0:30–1:30 | Open question → Chief complaint & HPI | 「你今日嚟睇咩嘢問題呀？」→「可唔可以由頭講起，邊度痛、幾時開始、點樣痛？」 | Open-ended start; lets patient tell their story; captures HPI systematically |
| 1:30–3:00 | Symptom analysis, red flags, radiation, neuro symptoms | 「有冇痛落腳？」「有冇腳痺、腳軟、或者控制唔到大小便？」「有冇發燒、體重輕咗？」「痛有冇喺夜晚痛醒你？」 | Red flags (cauda equina, malignancy, infection) are must-ask; discriminates serious from mechanical |
| 3:00–4:00 | ICE + Hidden agenda | 「你自己覺得可能係咩原因？」(Ideas) 「你最擔心嘅係咩？」(Concerns) 「你今日最希望我哋幫到你啲咩？」(Expectations) | ICE marks directly tested on CRF Q3; hidden agenda often = fear of cancer / worry about work |
| 4:00–5:00 | PMH, drugs, allergy, FH, social (occupation, exercise, mood), functional impact | 「你有冇長期病？食咩藥？」「你做邊行㗎？使唔使搬重嘢？」「呢個痛有冇影響你返工或者日常生活？」「心情點呀？」 | Biopsychosocial marks; occupation is key for mechanical LBP; mood screens for masquerade |
| 5:00–5:30 | Signpost & summarise | 「我同你總結吓：你主要係……我理解你擔心……，係咪啱？」 | Checking understanding; interpersonal marks |
| 5:30–6:00 | Close: brief plan, safety-net | 「我建議幫你做個身體檢查……如果之後出現腳軟、控制唔到大小便，要即刻嚟急症室。」 | Safety-net is essential for LBP; shows competence |
Uncovering the hidden agenda: The patient may present with pain but their real worry is cancer (family member had cancer?), inability to work, or fear of surgery. Ask 「你今日點解決定嚟睇醫生？」 ("What made you decide to come today?") — this often reveals the true RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? | 「邊度痛呀？可唔可以指俾我睇？」 | Localises: midline vs paraspinal vs radiating | Central = disc/stenosis; lateral = muscular/facet |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？突然定慢慢嚟？」 | Acute vs chronic; trauma? | Sudden + trauma → fracture; insidious → degeneration/inflammation |
| Character | What does the pain feel like? | 「點樣痛法？痠痛、拉扯痛、定電痛？」 | Shooting/electric = radicular | Radiculopathy / disc herniation |
| Radiation | Does pain go down the leg? Which leg? Below knee? | 「痛有冇落腳？去到膝頭以下嗎？」 | Sciatica = pain below knee in dermatomal distribution [1] | Disc herniation (L4/5, L5/S1); spinal stenosis |
| Aggravating | Worse with bending, sitting, coughing, walking? | 「彎腰、坐耐、行路會唔會痛啲？咳或者打乞嗤呢？」 | Cough/sneeze ↑ = ↑ intrathecal pressure → disc; walking = stenosis vs vascular | Disc prolapse; neurogenic claudication (relief by flexion) vs vascular claudication (relief by rest) [2] |
| Relieving | What makes it better? Rest? Bending forward? | 「點樣做會舒服啲？瞓低、向前彎？」 | Rest helps mechanical; forward flexion helps stenosis | Spinal stenosis ("shopping cart sign") |
| Morning stiffness | Morning stiffness > 30 min improving with activity? | 「朝早起身會唔會好僵硬？要幾耐先鬆返？郁吓會唔會好啲？」 | Inflammatory back pain: onset < 45y, > 3mo, morning stiffness > 30min, improves with movement [3] | Ankylosing spondylitis / SpA |
| Night pain | Pain waking you at night? | 「有冇痛到半夜醒？」 | Night pain = red flag for tumour/infection/inflammatory | Malignancy, infection, AS |
| 🚩 Cauda equina | Any difficulty passing urine, bowel incontinence, numbness around private parts? | 「有冇覺得去廁所困難、痾唔出、漏尿、或者屎忍唔住？下面有冇麻痺？」 | Cauda equina syndrome = surgical emergency [4] | Urgent MRI + surgical decompression < 48h |
| 🚩 Neuro deficit | Any leg weakness, numbness, foot drop? | 「隻腳有冇冇力、痺、或者隻腳板提唔起？」 | Progressive motor deficit = urgent referral | Severe disc herniation, CES |
| 🚩 Weight loss / fever | Unexplained weight loss? Fever? Night sweats? | 「有冇唔明原因瘦咗？有冇發燒、出夜汗？」 | Constitutional symptoms → malignancy / infection | Spinal metastasis, TB spine, epidural abscess |
| Trauma | Any recent injury or fall? | 「有冇跌親或者撞親？」 | Fracture (esp in osteoporosis) | Compression fracture |
| PMH | Cancer, osteoporosis, TB, IV drug use? | 「你有冇試過有癌症、骨質疏鬆、肺癆？有冇打針用藥？」 | Risk for pathological fracture, infection, mets | Metastatic spine disease, TB spine |
| Drug Hx | Steroids? Anticoagulants? Painkillers tried? | 「有冇食類固醇、薄血藥？食過啲咩止痛藥？有效嗎？」 | Steroid → osteoporotic fracture; drug efficacy guides Mx | Osteoporosis, drug-induced |
| Occupation | What is your job? Heavy lifting? Sitting? | 「你做邊行㗎？使唔使搬重嘢定坐成日？」 | Occupational risk + functional impact | Mechanical LBP, disability |
| Mood / Sleep | How is your mood? Sleeping OK? | 「心情點呀？瞓得好唔好？」 | Depression is a masquerade for chronic pain | Depression, chronic pain syndrome |
| Functional impact | How does this affect daily life, work, hobbies? | 「呢個痛影唔影響你返工、做運動、照顧屋企？」 | Social/functional problem for biopsychosocial Q | Biopsychosocial formulation |
Case Report Form Answer Builder
Write: "Lower back pain for [duration]"
High-yield points to capture:
- Site, onset, duration, character, radiation (below knee?), severity
- Aggravating factors (bending, coughing, walking) and relieving factors (rest, flexion)
- Presence/absence of red flags: neurological deficit, bladder/bowel, constitutional Sx, trauma
- Impact on function (work, ADLs, sleep)
- Previous episodes, investigations, treatments tried
| Likely RFC | How to Phrase |
|---|---|
| Pain worsening / not responding to painkillers | "Worsening lower back pain not responding to analgesics" |
| New leg symptoms (sciatica) | "New onset of shooting leg pain causing inability to work" |
| Fear of serious disease | "Concern about underlying serious cause of back pain" |
| Functional limitation | "Unable to work/care for family due to back pain" |
Tip: The RFC is the answer to 「你今日點解嚟睇醫生？」— phrase it as a single sentence combining the trigger and the patient's main concern.
| Component | Likely Content | Exact Wording to Write |
|---|---|---|
| Ideas | "I think I might have slipped a disc" / "Maybe it's just muscle strain" | "Patient thinks the pain may be due to a slipped disc" |
| Concerns | Fear of cancer, paralysis, needing surgery, inability to work | "Patient is worried the pain may indicate something serious like cancer" |
| Expectations | Wants X-ray/MRI, pain relief, physiotherapy referral, sick leave | "Patient hopes to get an X-ray and effective pain relief" |
For a typical FM station: Mechanical / non-specific low back pain (or Lumbar disc herniation with sciatica if radicular symptoms present).
Minimum supporting evidence:
- Mechanical LBP: localised lumbar pain, no radiation below knee, onset related to activity/posture, relieved by rest, no red flags, no neurological deficit
- Disc herniation/sciatica: radicular pain below knee in dermatomal distribution, +ve SLR, ± neurological deficit at specific root level
| DDx | One Key Discriminator |
|---|---|
| 1. Lumbar disc herniation / sciatica (or swap with main Dx) | Dermatomal leg pain below knee, +ve SLR, ↑ by cough/Valsalva |
| 2. Lumbar spinal stenosis | Neurogenic claudication: bilateral leg symptoms on walking, relief by sitting/flexion, variable claudication distance |
| 3. Ankylosing spondylitis | Young male, inflammatory back pain (onset < 45, > 3 months, morning stiffness > 30 min, improves with exercise) |
Alternative high-yield DDx depending on patient age/context: osteoporotic compression fracture, spinal metastasis, referred pain (renal/AAA)
| Domain | Problem |
|---|---|
| Biological | Lower back pain with/without radiculopathy causing impaired mobility |
| Psychological | Anxiety about serious underlying diagnosis (e.g. fear of cancer/paralysis); or low mood/sleep disturbance due to chronic pain |
| Social | Inability to work (esp. manual labour); reduced capacity to care for family; social isolation due to immobility |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Mechanical LBP (main Dx) | Localised paraspinal tenderness with full neurological exam normal | Palpate lumbar paraspinal muscles; check tone, power, reflexes, sensation in both LL | Tenderness without neurological deficit supports non-specific mechanical cause |
| Disc herniation / sciatica | Positive straight leg raise (SLR) test at 30–70° [6] | Patient supine; passively flex hip with knee extended; positive = reproduction of radicular pain/paraesthesia below knee at 30–70° | Indicates L5/S1 nerve root irritation; most specific bedside test for disc herniation |
| Spinal stenosis | Neurogenic claudication with relief on flexion | Observe gait; symptoms reproduced by walking/extension, relieved by sitting/forward flexion ("shopping cart sign") | Distinguishes from vascular claudication (relief by standing still); flexion ↑ spinal canal diameter |
| Ankylosing spondylitis | Reduced lumbar spine ROM + positive modified Schober test [3] | Mark 10 cm above and 5 cm below PSIS dimples; on forward flexion, distance should ↑ by ≥ 5 cm; < 5 cm = positive | Indicates reduced spinal mobility characteristic of AS |
| Osteoporotic compression fracture | Midline spinous process tenderness + kyphosis / height loss | Percuss each spinous process; measure height | Localised bony tenderness at fracture level; loss of height/kyphosis from wedge fracture |
| Cauda equina syndrome | Saddle anaesthesia + reduced anal tone | Test perineal sensation (S2–S4); per rectal exam for anal tone | Pathognomonic; indicates S2–S4 involvement requiring emergency surgery |
Must-Not-Miss Red Flags (Urgent Referral)
- Cauda equina syndrome: urinary retention/incontinence, faecal incontinence, saddle anaesthesia, bilateral leg weakness → Emergency MRI + decompression within 48 hours [4]
- Progressive neurological deficit: worsening foot drop or motor weakness → urgent specialist referral
- Suspected malignancy: age > 50, history of cancer, unexplained weight loss, night pain unrelieved by rest → urgent imaging
- Spinal infection: fever + back pain + immunosuppression/IVDU → urgent blood cultures + MRI
- Abdominal aortic aneurysm: pulsatile abdominal mass + back pain in elderly → emergency vascular referral
Top traps that lose marks:
| Trap | How to Avoid |
|---|---|
| Forgetting to ask about bladder/bowel symptoms | Always ask cauda equina screen — examiners specifically look for this |
| Not distinguishing inflammatory vs mechanical back pain | Ask about morning stiffness duration, improvement with exercise, age of onset |
| Missing the hidden agenda | Don't rush symptom analysis; ask ICE and "why today?" |
| Writing vague RFC like "back pain" | Be specific: include trigger/concern/functional impact |
| Forgetting occupation and functional impact | Needed for social problem in biopsychosocial formulation |
| Confusing neurogenic vs vascular claudication | Neurogenic: variable distance, relief by flexion; Vascular: fixed distance, relief by standing [2] |
| Not safety-netting | Always give cauda equina warning at close of consultation |
Shortest safe management / safety-net line: 「如果你突然間覺得腳好冇力、去唔到小便、或者下面麻痺，要即刻去急症室，唔好等。」 ("If you suddenly develop leg weakness, difficulty passing urine, or numbness around your private parts, go to A&E immediately — don't wait.")
High Yield Summary
What to ASK: Site/onset/character/radiation below knee, aggravating (cough, walk) & relieving (rest, flexion), morning stiffness duration, bladder/bowel/saddle, leg weakness/numbness, night pain, weight loss/fever, occupation, mood, ICE + "why today?"
What to WRITE: Precise chief complaint with duration; one clear RFC (not just "back pain"); ICE with patient's own words; most likely diagnosis with minimum 2–3 supporting features; DDx with discriminators; biopsychosocial problems (at least one each); physical sign = SLR for sciatica or localised tenderness for mechanical LBP.
What NOT to MISS: Cauda equina screen (every patient), inflammatory vs mechanical distinction, red flags for malignancy/infection, safety-netting at close.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 226. Lumbar Spine Pathology_Part E.pdf (Pathologies including disc herniation, spinal stenosis) [2] Senior notes: Ryan Ho Cardiology.pdf (p205, neurogenic vs vascular claudication table) [3] Senior notes: Maksim Medicine Notes.pdf (p324, Ankylosing spondylitis clinical features and physical examination) [4] Senior notes: Maksim Surgery Notes.pdf (p222–223, Approach to spine diseases, cauda equina syndrome) [5] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1706, Mechanical vs inflammatory back pain) [6] Senior notes: Ryan Ho Fundamentals.pdf (p148, SLR test technique and interpretation) [7] Senior notes: Block A - Back pain in an elderly woman_ osteoporosis and related fractures.pdf (osteoporotic fractures)
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