A Modern Epidemic

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THERE are many conditions that now appear far more common than previously.

Grant has just arrived in the emergency department with one of them. He is howling with pain with any slight movement, and every change of direction of the ambulance trolley through our temporary (slightly serpentine) ambulance entrance brings a further grimace and expletive.

He is met by our newly introduced multidisciplinary triage team. An experienced group of nurses and a consultant in emergency medicine are now on hand to meet all patients who arrive by ambulance as soon as they enter the emergency department at the Royal Infirmary, reducing the time to get pain relief to patients as well as streamlining the individual investigations (if any) that patients may require as part of their assessment.

We go and introduce ourselves to Grant, who is a 34-year-old IT consultant. It turns out that Easter has triggered his first foray into the garden, and when lifting some grass cuttings, he got a slight twinge in his lower back. He decided to lay up for the rest of the long weekend, and on trying to return to his work today, he has been crippled by excruciating pain in the right side of his lower back.

He certainly looks incredibly uncomfortable. He is holding himself in a half-bent position on his left side, clutching his right flank. We take some routine observations (all normal) and administer some pain killers to Grant, which will take 30 or so minutes to take effect, and move him into one of our other cubicles so we can examine him further.

Once his pain has settled a little, I go back to see him, take a fuller history of his painful symptoms and examine his abdomen, spine, legs and nervous system to get a clear picture of what is most likely going on. We also get a urine sample to help us exclude a kidney stone as the cause of his pain. Fortunately, we do not need to also exclude pregnancy.

There are several things that we need to consider in patients with back pain, and we use a combination of various types of information to make sure we are not missing something serious or life-threatening.

We need to be confident that Grant does not have a ruptured aneurysm (a swelling of the large artery that runs through your abdomen – wrong age group and not felt on examination), a 
fracture of his spine (no trauma, no spinal bony tenderness), any suggestion of infection in the spine (unlikely due to patient characteristics, history of pain, lack of fever, lack of tenderness), cancer of the spine (very unlikely in this age group, lack of other constitutional symptoms, time course of history) and finally we need to be clear that there is no compression of nerves leaving the spinal canal (normal neurological history and examination).

With all these considerations achieved, and noting that none require any special tests as such, we can safely conclude that Grant’s pain is highly likely to be caused by a muscular injury to his back.

This should normally be met with some relief by patients, but is often received with an element of disappointment.

“But the pain is killing me, doctor!”

Yes, the severity of symptoms are often not proportional to the significance of the underlying diagnosis.

However, that in no way should demean the pain itself. The difficulty with pain caused by muscular back injuries is that it is difficult to control completely. So then comes the testing next part of the consultation, which involves me explaining that whilst the underlying diagnosis is not concerning, the pain from it has probably been made slightly worse by a period of inactivity following the initial injury, that it is unlikely that we will be able to take the pain away with conventional pain killers, and that the recovery plan for this condition requires a fair amount of hard work on the part of the patient to regain flexibility and strength in the back, rather than by medical services.

“But you’re a doctor, you’re meant to take the pain away.”

I hold my hands up at this point – it’s a fair cop. With this condition, which is now so common, us medics do not have the tools to eradicate the pain associated with it. We do have reasonable medicines to make the pain bearable, though, and we know that if you can maintain and improve the mobility and muscular strength in the lower back, it is unlikely that you will have really painful symptoms for more than two weeks or so.

The big “if” in that plan, though, requires ourselves to take some ownership of our wellbeing, not doctors, nurses or physiotherapists. Being active regularly, maintaining fitness, controlling our weight and leading a life of enjoyment through moderation is the key to avoiding healthcare altogether.