Initial pre-referral workup

Clinical history

Back pain is uncommon in young children, but common in adolescence.

Watch out for red flags:

• pain lasting more than four to six weeks
• pain that wakes someone from sleepradicular symptoms
• constitutional symptoms/weight loss

Physical examination

Look for any evidence of spinal deformity as well as radicular signs or any abnormal neurologic findings.

Investigations

Most back pain is self-limited and requires no medical imaging.

If there is concern for spinal deformity (scoliosis/kyphosis) then an upright complete spine x-ray (PA and lateral) is most appropriate. An EOS scan would be the best option in the Greater Melbourne area.

If there is concern of abnormal neurologic findings then an MRI is the best imaging modality in most cases.

GP management

Back pain without radiologic abnormality and in the absence of radicular symptoms should be managed conservatively.  Referral to local physiotherapy or similar would be appropriate. Heat and massage can be helpful adjuncts. 

Short courses of oral analgesia may be appropriate when necessary.

Back pain without radiologic abnormality or radicular symptoms does not need specialist referral to the RCH.

Indications for specialist referral

Routine

• patients with radicular signs or symptoms - obtain axial imaging (CT or MRI) prior to referral if possible