Back Pain: Chronic, Complex & Concerning (Part 2)

  

Welcome to Part 2 – let's move beyond the acute setting to focus on the challenges of chronic low back pain, the impact of psychosocial factors (yellow flags), and how to recognise red flags that may signal serious underlying pathology. 

🩺 Clinical vignette – Part 2: When back pain won’t go away

Emily is a 47-year-old high school teacher presenting with persistent low back pain ongoing for 4 months. It started gradually and isn’t linked to a specific injury. She describes it as deep and aching, occasionally radiating into her buttocks (but not below the knee). It’s worse after prolonged sitting.

She’s frustrated—she’s tried bed rest, heat packs, and over-the-counter meds. She’s worried “something is being missed” and wants an MRI.

Her mood is flat. She’s been off work for several weeks. No weight loss, fevers, trauma, or neurological symptoms. Past history includes mild anxiety.

On exam:

• Normal gait
• Tenderness over the lower paraspinal muscles
• Neurological exam: normal
• No red flags identified

🧠 Your task:

Does this patient need imaging?

How does your management plan differ from acute LBP?

What role do psychosocial factors play?

Emily has been off work for weeks, worried her spine is permanently damaged, and avoids all activity. Her pain isn’t improving. No red flags, but lots of yellow ones. 

🟨 What are yellow flags?

Psychosocial factors that can amplify or prolong back pain:

• Fear of movement or re-injury
• Catastrophising  
• Passive coping style
• Belief that pain = damage
• Low mood or anxiety
• Work dissatisfaction or conflict
• Expectation of ongoing disability
• Social withdrawal or lack of support

These flags aren’t “psychology-only” issues—they're core to biopsychosocial pain management.

📌 Clinical relevance (RACGP, eTG Pain, WorkCover NSW guidelines):

✅ Identify yellow flags early

✅ Use tools like the Örebro Musculoskeletal Pain Questionnaire https://buff.ly/m29IwB9 

✅ Reassure and educate: movement is safe

✅ Refer for multidisciplinary care if flags are present

✅ Avoid over-medicalising the pain (e.g. unnecessary imaging, scripts, or referrals)

📚 Yellow flags mean recovery needs more careful multidiscplinary management. Understanding yellow flags = understanding why some patients don’t get better—and how to help them before things get worse.

✅ Key reasoning for Emily:

• This is non-specific chronic low back pain
• No red flags → Imaging not indicated at this stage
• Focus on biopsychosocial model: pain education, graded activity, address mood/anxiety, set functional goals
• Refer for physiotherapy or a multidisciplinary pain program
• Avoid opioids

📌 Chronic LBP isn’t just about the spine—it’s about how people think, feel, move, and function.

🩺 Clinical vignette – Part 3: When back pain is something serious

Raj, a 67-year-old retired accountant, presents with new onset lower back pain that’s been gradually worsening over the past month. He describes it as a deep, constant ache that wakes him at night. It’s unrelieved by rest or position changes.

He reports feeling more tired lately, and mentions unintentionally losing 4 kg over the past 2 months. No trauma. He denies leg weakness, bowel/bladder changes, or fevers.

Past history: prostate cancer treated 6 years ago with radiotherapy. He’s been well otherwise.

On exam:

• Vitals: normal
• Mild lumbar tenderness, no deformity
• Normal neurological exam
• No signs of infection

🧠 Your task:

What red flags are present?

Would you order imaging—and if so, what type?

How would you manage this patient?

🔴 Red Flags in Back Pain: Know When to Worry

Red flags are clinical indicators that suggest a serious underlying pathology in patients presenting with back pain. 

🚨 Key Red Flags to Remember

1. Malignancy

• History of cancer
• Unexplained weight loss
• Age >50
• Pain that’s constant, progressive, or worse at night
• Not relieved by rest

2. Infection (e.g. vertebral osteomyelitis, discitis, epidural abscess)

• Recent infection (e.g. UTI, skin)
• Immunosuppression
• IV drug use
• Fever, rigors
• Localised spinal tenderness

3. Fracture

• Significant trauma (esp. in younger patients)
• Minor trauma in osteoporotic or elderly patients
• Prolonged corticosteroid use
• Age >70

4. Cauda Equina Syndrome (neurosurgical emergency)

• Bilateral leg weakness or sciatica
• Saddle anaesthesia / parasthaesia
• Urinary retention or incontinence
• Loss of anal tone / faecal incontinence
• Sexual dysfunction

5. Inflammatory back pain 

• Age <40
• Morning stiffness >30 min
• Improves with exercise (not rest)
• Nocturnal pain
• Associated with IBD, psoriasis, uveitis

🖼️ What to Do If Red Flags Are Present

✅ Don’t delay – investigate early

✅ MRI spine is preferred for suspected malignancy, infection, or cauda equina

✅ Urgent referral to ED if neurological signs present

✅ Consider bloods depending on suspicion

✅ Always document red flag assessment clearly

💬 Rule out the rare, so you can confidently manage the common.

✅ Key reasoning for Raj’s case :

• This is subacute back pain with red flags

• Age >50
• Night pain and weight loss
• History of malignancy

• High suspicion for metastatic disease

📌 Imaging is indicated immediately

• MRI spine preferred to evaluate for bony lesions 
• Consider bloods as part of initial workup
• Urgent referral depending on findings

🛑 Missing red flags = missed diagnoses.

💬 Know the difference between when to reassure and when to refer. Back pain is common—but missing red flags can have serious consequences.