Back, neck, bone and soft tissue pain

Recognising urgent causes

Most low back pain is not explained by a dangerous structural lesion, but initial assessment must identify serious alternatives. Ask about trauma, cancer, infection, steroid use, osteoporosis, neurological symptoms and functional change. Fever, systemic illness, progressive weakness, saddle sensory change or new urinary retention raises urgent investigation. Cauda equina syndrome needs emergency spinal assessment and MRI; do not wait for every classic sign or a lost anal reflex. Cancer, epidural infection and fracture can present with a relatively normal early examination.

Describe location, radiation, duration, triggers and disability. Examine gait, relevant joints and neurology, including power, sensation and reflexes. Leg pain following a root distribution may be radicular, while referred hip pain and vascular claudication can mimic a spinal problem. Back pain with hypotension or abdominal findings raises aortic disease. “Mechanical” pain behaviour reduces some concerns but does not by itself exclude malignancy or infection. Use serial assessment when the story evolves rather than relying permanently on the first benign impression.

Imaging and conservative care

The Australian Low Back Pain Clinical Care Standard discourages routine early imaging without a suspected serious cause or another indication. Degenerative changes are common in asymptomatic adults and may lead to unnecessary procedures if overinterpreted. Explain that imaging should answer a clinical question. When a fracture, infection, malignancy or neurological emergency is suspected, choose appropriate imaging promptly; a general rule against routine scans must not be used to withhold indicated MRI or CT. Investigations follow risks and examination rather than the patient's pain score alone.

For uncomplicated pain, give a clear explanation, encourage tolerable activity and plan review. Avoid prolonged bed rest and catastrophic language about a “crumbled spine.” Non-drug strategies, physiotherapy and work/activity modification can support recovery. Analgesia depends on contraindications and expectations: NSAIDs may be unsuitable with renal, GI or cardiovascular risks, and opioids are not a default long-term solution. Assess psychosocial contributors such as fear of movement, work stress and low mood without dismissing physical symptoms. Agree achievable functional goals rather than promising immediate elimination of all pain.

Neck pain, bones and osteoporosis

After neck trauma, apply a validated clearance pathway only to its intended population; severe pain, neurological change or unreliable examination warrants appropriate protection and imaging. Non-traumatic neck pain with fever, new neurological signs or a mass needs another pathway. Distinguish cervical radiculopathy from myelopathy: gait disturbance, hand clumsiness and long-tract signs suggest cord disease. Persistent hoarseness, dysphagia or neck swelling may indicate an ENT or malignancy problem rather than a musculoskeletal strain. Offer appropriate safety advice for driving when rotation or sedation limits control.

Fragility fracture signals increased future fracture risk. Review falls, vision, medicines, nutrition, calcium/vitamin D adequacy, secondary causes and bone-density assessment when appropriate. Anti-resorptive treatment is selected according to fracture risk, renal function, dental considerations and patient preference. A normal calcium result does not rule out osteoporosis. Do not stop or delay an established denosumab course casually: discontinuation requires a planned transition because rebound bone loss and vertebral fractures can occur. Acute hip pain with inability to bear weight after a fall needs an occult-fracture pathway even if plain films look normal.

Soft tissues and chronic pain

Local tendon pain relates to loading and examination; graded rehabilitation often matters more than repeated injections. A hot swollen joint raises infection or crystal disease and may need aspiration urgently. Bilateral shoulder/hip girdle stiffness in an older person raises polymyalgia rheumatica; screen for GCA symptoms before assuming simple osteoarthritis. Diffuse pain with fatigue and sleep disturbance can occur in fibromyalgia, but the diagnosis requires an appropriate assessment of alternative disease. A positive symptom label must not stop investigation of new red flags in later visits.

Complex regional pain syndrome features disproportionate pain with sensory, vasomotor, sweating/oedema and motor/trophic abnormalities after an injury, assessed against clinical criteria. Early rehabilitation and specialist pain support can limit disability. Avoid telling the patient the symptoms are imagined because imaging is normal. Chronic pain management combines physical, psychological and social approaches with medication review. Shared decisions should address opioid harms, tolerance, constipation, falls and safe tapering; abrupt forced cessation can itself harm a dependent patient. Document the agreed plan and continuity arrangements.

Applied decisions

A worker with a few days of back pain, normal neurology and no systemic warning signs generally needs activity advice, suitable symptom control and review, rather than immediate MRI. A patient with worsening bilateral leg weakness and new retention needs emergency imaging and specialist assessment. A person with focal night bone pain, weight loss and a cancer history needs investigation even if a previous X-ray was normal. These cases test whether the clinician can distinguish low-value routine imaging from necessary urgent investigation.

At follow-up, assess change in function and examination rather than simply renewing analgesics. Provide specific return instructions for weakness, bladder/bowel change, fever or escalating systemic symptoms. Address barriers to physiotherapy, safe work and home support; an inaccessible treatment plan is unlikely to work. Discuss expected recovery realistically and use an interpreter when needed to check understanding of the warning signs.

Low Back Pain Clinical Care Standard.

Review checkpoints

• Routine imaging is not recommended for uncomplicated acute low back pain.
• New bladder dysfunction or saddle sensory loss requires urgent assessment for cauda equina syndrome.
• Focal bone pain with systemic symptoms needs investigation for infection or malignancy.