Back Pain

Real Cases, Real Thinking, Real Medicine

Amie and Ben discuss a case of 49 year-old male with back pain. 

Can Amie figure out what is going on? 

As you listen, ask yourself: can you figure out the diagnosis? What would you have done in the situation?

Links & Resources

• RCPE Education: rcpe.ac.uk/education

Connect With Us

• Email: amie@homeofmedicine.com
• YouTube: Home of Medicine Channel

Disclaimer: All patient stories discussed in Home of Medicine are informed by real patient interactions. However, all identifying details have been removed or appropriately modified to protect patient confidentiality. 

This podcast is intended for education and professional development and should not replace independent clinical judgement or specialist consultation.

Transcript

Introduction

Host (Ben): Hello and welcome to a new episode of the Home of Medicine Podcast, in association with the Royal College of Physicians Edinburgh. My name is Ben Lovell, and I'm a consultant in acute medicine working in London. I'm joined by my co-host.

Co-host (Amie): Hi, I'm Dr. Amie Burbridge, also a consultant in acute and general medicine, and director of professional development at Lincoln Medical School.

The Case: A Chronic Back Pain Flare-Up

Ben introduces this week's case with a twist: rather than a new presentation from the emergency department, it's a patient he inherited on the ward during a Monday morning round — already two days into an admission.

Key background on the patient:

• 49-year-old man, admitted with a severe flare of long-standing chronic lower back pain
• Pain so severe he was unable to mobilise at home
• Well known to the hospital's complex pain clinic
• Most recent MRI spine, two months prior, confirmed multi-level disc degeneration with bilateral L3/L4 radiculopathy from compressed discs
• Not yet known to neurosurgery; management plan was conservative
• Previously tried nerve root injections with no significant relief
• On high-dose neuropathic pain medication: gabapentin 900mg three times daily and amitriptyline 50mg at night
• Confined to bed at home, unable to reach the toilet, before being brought to the emergency department

Host (Ben): Is this a case you're familiar with? What's your usual strategy when you meet a patient like this?

Ruling Out an Acute Cause First

Co-host (Amie): Absolutely, I've seen very similar presentations before. My job as an acute physician is to make sure this gentleman doesn't have an acute cause for his back pain. What I don't want to do is assume this is simply a flare of chronic back pain just because he has a complicated spinal history.

She outlines her differential thinking:

• Could this be cauda equina syndrome?
• Is the pain spinal, muscular, or sacroiliac in origin?
• Could there be an infection or a fracture?
• Given his level of spinal degeneration, could he have osteopenia and an osteoporotic fracture?
• Has he had any trauma?
• Has he actually been taking — and absorbing — his medication?
• Are there any additional red-flag symptoms: fever, weight loss, appetite change, breathing problems, bowel habit change, chest pain?

Key takeaway: A chronic diagnosis should never be assumed purely because a patient has a well-documented history of it. Every acute presentation deserves its own fresh assessment.

Host (Ben): What's wrong with easy?

Co-host (Amie): Nothing's wrong with easy — and that's exactly what I have to remind myself. Sometimes the honest answer probably is "this is chronic back pain, treat and observe." But I always want to check there isn't something else going on.

Pattern Recognition: Does This Fit?

Ben agrees, adding a practical technique he uses:

Host (Ben): If someone presents with a condition they've had many times before, we have to check it fits the pattern — and the way I check that is by asking the patient directly. Does this feel like your usual flare, or does it feel different?

He notes this approach works well for patients with recurring conditions such as cyclical vomiting syndrome, where most presentations do match the known pattern — but occasionally something new, like gastroenteritis, is layered on top.

Managing a Chronic Pain Flare-Up: Do's and Don'ts

This section covers the hosts' practical approach to opioid stewardship in chronic pain.

Avoid unnecessary admission. Lying flat for 23 hours a day in hospital can worsen a chronic pain flare rather than help it. The first goal is to try to manage flares at home wherever safely possible.

Check for an existing pain plan. Many patients with chronic pain disorders have a documented plan from their pain team outlining what should — and shouldn't — be tried during a flare.

Be cautious starting opioids, particularly long-acting ones. Ben explains the clinical rationale:

"Starting long-acting or modified-release opioid preparations can send patients on a downward trajectory over time. It affects the pain threshold, meaning future flares need progressively larger doses to achieve the same relief."

He recalls historical cases of patients on morphine sulfate tablets (MST) at 150mg twice daily just to feel normal — doses that began with well-intentioned attempts to improve comfort.

Ask about the flare's typical trajectory. Ben asks patients how long it usually takes them to "turn the corner" during a flare. Knowing the expected timeline (e.g., three days in hospital, a further week to recover) helps set expectations for both patient and team.

Avoid "splitting" the care team. Blaming a restrictive pain-team plan ("I can't give you morphine because the pain team says no") damages the patient's trust in the wider service and doesn't help long-term.

In this case, Ben negotiates a plan with the patient: rest for the day, gentle mobilisation attempted the next morning, and no push for physiotherapy until the patient feels able.

Is an MRI Needed Again?

Ben explains to the patient why he isn't ordering a repeat MRI on day one:

"We do MRIs to get an answer. I don't need an MRI to make you feel better — I need one to answer a clinical question, and I already know why you're in pain. The scan from two months ago gave me that answer."

The Subjectivity of Pain

Co-host (Amie): We have to be very careful not to underestimate people's pain. Pain is a subjective sensation, not an objective one — who are we to question it? At the same time, I can't help wondering: is this medication-seeking behaviour? But I can't make that judgement after meeting someone once, and I don't want to stereotype.

A Personal Story

Ben shares a personal experience of being a surgical patient in severe, undertreated post-operative pain — and being told by staff that "most people aren't in this much pain after this procedure." He reflects that this experience changed how he approaches patients reporting severe pain:

"If a patient tells me they're in agonising pain, I have no way of disproving that — and no good reason to try."

He balances this empathy against clinical caution about opioid-related risks, describing a scenario nobody wants to hear about their patient: over-sedation, pinpoint pupils, and a dangerously low respiratory rate from repeated morphine top-ups.

Key distinction he draws: short courses of strong analgesia make sense for acute injuries (fractures, surgery, trauma) where healing is expected. For a flare of a chronic condition, introducing a potent opioid is riskier, because it's unclear whether it helps long-term remission — and it may simply raise the bar for what's needed next time.

Clinical Red Flags: What Would Signal Something New?

Co-host (Amie): How do you know there wasn't anything new going on?

Host (Ben): I ask the patient directly whether this feels like the usual flare or something different. Red flags I listen for include:

• New numbness or weakness down a limb that wasn't there before
• Loss of bladder or bowel control
• New fever
• New vomiting

He also performed a full examination, including a neurological assessment of the legs, and reviewed the patient's vital signs — all within normal range at that point. The admitting doctor's earlier neurological exam had also been reassuring.

Could He Have Gone Home?

Co-host (Amie): Are you thinking maybe this patient shouldn't have been admitted at all?

Host (Ben): I doubt it. Sometimes admission is simply the safest option — you can't discharge someone who is unable to walk. I never criticise a colleague for admitting a patient if that was the safest call.

A Change in the Bloods

By day three, the patient's pain remained severe. Repeat bloods showed his CRP had risen to 104, up from a normal baseline on admission.

Co-host (Amie): A CRP of 104 is pathological — that's a meaningful signal of inflammation somewhere in the body. Her differential at that point included:

• Localised spinal infection or irritation
• A vertebral fracture (would check ALP, alkaline phosphatase)
• Infection elsewhere in the body
• A spinal infection such as discitis
• A DVT (immobility can also raise CRP)
• Hospital-acquired pneumonia (though thought less likely this early in admission)

She recommends a full panel: white cell count, neutrophils, kidney function, and liver function.

Host (Ben): I remember learning in medical school that "back pain plus a high CRP equals discitis until proven otherwise." In real life, it doesn't always bear out that cleanly — but you do have to think about it.

Examining for Spinal Infection

Ben describes his bedside assessment, looking specifically for signs consistent with a spinal infection:

• Palpating the spine — severe tenderness to light touch is a classic feature of discitis
• Inspecting the skin over the back, to rule out a missed case of shingles (herpes zoster), which can cause severe localised pain
• Asking about urinary and chest symptoms

On examination, the patient's back was tender but not severely so — not the dramatic "can't bear to be touched" tenderness Ben associates with a spinal infection.

A Working Explanation Is Found

During the skin inspection, Ben found a patch of cellulitis on the patient's left leg, partially hidden beneath a compression stocking.

"We know chronic pain can flare during intercurrent infections. I thought — if he's having a systemic response to a skin infection, maybe that's why his pain is higher than usual."

He started the patient on flucloxacillin for the cellulitis and continued the ward round.

Does This Feel Complete?

Co-host (Amie): This feels like something's missing.

She probes further, asking about the patient's white cell count and neutrophils (both normal), and questions why a 49-year-old had developed cellulitis in the first place — prompting a discussion about looking for an underlying skin breach, such as an insect bite, cut, or athlete's foot (none were found).

Key takeaway: A plausible finding doesn't always mean the search is over. Ask why a new finding occurred, not just that it occurred.

A Nurse Raises the Alarm

Later that afternoon, the patient's bedside nurse — who had cared for him since admission — flagged a clear deterioration: he was now lying completely flat, log-rolling to move, and unable to tolerate the head of the bed being raised. She said this was a marked change from two days earlier.

Ben asked the on-shift doctor to reassess. A repeat, more thorough neurological exam found:

Complete sensory loss from L3 downward on the left leg — a new finding not present on admission or the previous day's (limited, pain-affected) exam.

Host (Ben): At that point, I said: we need an MRI spine.

Escalation and Specialist Referral

An MRI spine was carried out that day. Neurosurgery and infectious diseases (ID) were involved in ongoing management, and the patient's antibiotic treatment was escalated. [Full imaging findings and final diagnosis are discussed in the episode audio and are intentionally not detailed here to preserve the case-based format of the podcast.]

Reflecting on the Case: Cognitive Bias in Diagnosis

Hickam's Dictum vs. the "Zebra"

Ben reflects that the case is a reminder of Hickam's dictum — the idea that a patient "can have as many diseases as they please" — layered against the more familiar teaching of favouring common diagnoses over rare ones.

Naming the Bias: Satisficing and Premature Closure

Ben identifies two specific reasoning traps at play in his own thinking:

• Premature closure — stopping the diagnostic process once a plausible explanation is found, before it has been fully tested
• Satisficing — accepting an explanation (in this case, the cellulitis) that seems "good enough" to explain the presentation, and mentally moving on

He credits an earlier podcast guest, cognitive-bias researcher Dr. Pat Croskerry, for introducing these concepts around human factors and diagnostic reasoning. (Note: the recording appears to mis-hear the guest's surname; Croskerry is a well-known author on cognitive bias in emergency and acute medicine.)

Was There Bias Toward This Patient?

Co-host (Amie): Can I ask a challenging question — do you think you had any bias toward this patient because of his chronic back pain history?

Host (Ben): Probably, yes — not a prejudice against people with chronic pain, but a cognitive bias in how I reason: attributing new symptoms to an existing chronic diagnosis rather than considering a new acute cause.

Reframing With Pretest Probability

Co-host (Amie): I don't think you did anything wrong, Ben. We see so many patients with chronic back pain — we also have to think about pretest probability.

She reasons through it: a 49-year-old man, immunocompetent, with no prior history of spinal infection, had a genuinely low pretest probability of discitis at initial assessment. What mattered was recognising when that probability changed — as the CRP rose, pain worsened, and sensation changed — and re-questioning the working diagnosis at that point.

Key takeaway: Diagnostic reasoning isn't static. A low initial probability of a rare diagnosis should rise — and prompt re-investigation — as new clinical information emerges.

Self-Reflection Without Self-Criticism

Host (Ben): I don't beat myself up too much — I saw 150 patients that week, and this was one of them. I'm not perfect, and I'm not all-knowing. But I do want to reflect and ask what I could have done differently, without swinging to the opposite extreme of over-investigating every patient.

Co-host (Amie): Common things are common, and rare things are rare — we can't diagnose everybody with a rare condition. Over-investigation carries its own harms: unnecessary tests, unnecessary treatment, and strain on limited resources.

Shared Decision-Making

What Does the Patient Actually Want?

Host (Ben): What does the patient want, or what does the patient think they need?

Co-host (Amie): That's such an important question. It brings us to shared decision-making — a core part of clinical reasoning. The patient wanted an MRI. I'm not saying that was necessarily "correct," but it's the same dilemma with a patient who declines a recommended treatment: how do you manage the plan once you know what the patient wants?

The Power Dynamic in Consultations

Host (Ben): Patients of sound mind can decline any intervention — but they can't demand one a doctor doesn't think is appropriate. That power imbalance is part of why some patients feel they need to "make their case" strongly to be taken seriously.

He's clear that the takeaway isn't "always give the patient what they want" — but that patients often have good insight, and clinicians have a duty to listen, explain their reasoning, and aim for a genuinely collaborative decision wherever possible.

Closing Thoughts

Co-host (Amie): This episode used a different part of my brain — it's interesting how differently we each think, even when we usually arrive at the same endpoint by different routes.

Host (Ben): Thanks for playing along today, everyone. If you guessed the case early, you're a better doctor than me — that's part of the fun. Please share the podcast with colleagues, and get in touch if you have a case idea or feedback. Until next time, goodbye.

Co-host (Amie): Thank you very much. Goodbye.

In this episode of the Home of Medicine Podcast, hosts Dr. Ben Lovell and Dr. Amie Burbridge work through a real acute medicine case: a 49-year-old man admitted with a severe flare of long-standing chronic lower back pain. The hosts model the clinical reasoning acute physicians use to decide whether a symptom flare fits a patient's known pattern or signals a new, potentially serious problem. Along the way they discuss opioid stewardship in chronic pain, the diagnostic value of trending inflammatory markers, and the cognitive biases that can cause doctors to close a case too early.

Frequently Asked Questions

How do doctors tell whether a chronic pain flare-up is "the usual pattern" or something new? They ask the patient directly whether the current episode feels identical to previous flares, then screen for red-flag features such as new neurological symptoms, fever, weight loss, or a change in bowel or bladder habit. A full examination and baseline observations are repeated even when the underlying condition is already well documented.

Why are acute physicians cautious about starting opioids for a chronic pain flare-up? Long-acting opioids can lower a patient's pain threshold over time, meaning future flares require progressively higher doses to achieve the same relief. Physicians instead favour short-term, non-escalating strategies and lean on existing pain-team management plans where available.

What does a rising CRP mean in a patient with known chronic back pain? A significant rise in C-reactive protein (CRP) — a blood marker of inflammation — from a normal baseline suggests a new inflammatory or infective process rather than a straightforward pain flare. It prompts a fuller work-up, including a repeat examination, full blood panel, and consideration of infective, vascular, or fracture-related causes.

How should clinicians balance a patient's request for a scan against clinical judgement? Best practice is shared decision-making: listening carefully to why the patient wants the investigation, explaining the clinical reasoning behind the plan, and being willing to revisit that plan if new information emerges. Patients can decline a recommended intervention, but a scan is offered based on clinical indication rather than request alone.

What cognitive biases can cause a doctor to miss a new diagnosis in a patient with an existing chronic condition? Two key concepts discussed are premature closure (settling on a diagnosis before fully testing it) and satisficing (accepting an explanation that is "good enough" and stopping further inquiry). Both are more likely when a plausible, familiar explanation is available for a patient already known to the clinician.

What happens when a patient with years of documented chronic back pain turns up in far more pain than usual — and everything about their history says "this is just another flare"? In this case-based episode, hosts Ben Lovell and Amie Burbridge walk through a real acute medicine ward round in real time, thinking aloud the way they would with a learner at the bedside.

Listeners will learn:

• How to structure a clinical assessment when a patient's story matches a condition they already have
• A practical framework for safely managing opioid analgesia in chronic pain flares
• How to interpret a rising CRP and when it should prompt re-investigation
• The difference between Hickam's dictum and Occam's razor in real-world diagnosis
• How premature closure and satisficing show up in everyday clinical reasoning
• How to hold a shared decision-making conversation when a patient wants a test you don't think they need

Chapter Markers

 | Timestamp | Chapter | 00:12 | Welcome and podcast introduction
| 00:36 | Meet the hosts: acute and general medicine consultants
| 00:43 | Case introduction: a 49-year-old man with a chronic back pain flare
| 03:25 | First principles: ruling out an acute cause before assuming "just a flare"
| 05:40 | Why "easy" answers can be risky in acute medicine
| 06:09 | Pattern recognition: does this fit the patient's usual presentation?
| 06:29 | Strategies for managing a chronic pain flare-up in hospital
| 10:34 | The subjectivity of pain and the risk of under-treating it
| 12:17 | A personal story: being a patient in unmanaged post-operative pain
| 17:36 | Clinical red flags that distinguish "usual" from "new"
| 19:02 | Weighing up safe discharge versus admission
| 20:10 | A change in the bloods: interpreting a rising CRP
| 21:52 | Examining for spinal infection at the bedside
| 23:45 | A working explanation is found — but does it feel complete?
| 24:58 | Digging deeper: where did this new finding come from?
| 25:15 | A concerned nurse flags a deterioration
| 26:13 | A new neurological finding changes the plan
| 26:43 | Escalation: repeat imaging and specialist referral
| 28:05 | Hickam's dictum: when patients have more than one thing going on
| 28:33 | Naming the bias: premature closure and satisficing
| 29:45 | A challenging question: was there bias at play?
| 30:25 | Reframing with pretest probability
| 31:47 | Self-reflection without self-flagellation
| 33:14 | Common things are common — the case for measured investigation
| 33:58 | What does the patient actually want?
| 34:43 | Shared decision-making and the power dynamic in consultations
| 36:04 | Closing thoughts and how to get in touch

People

• Dr. Ben Lovell — Host; consultant in acute medicine, London
• Dr. Amie Burbridge — Co-host; consultant in acute and general medicine; director of professional development, Lincoln Medical School
• Dr. Pat Croskerry (likely intended name; referenced re: cognitive bias/human factors) — previous podcast guest, referenced for work on satisficing and diagnostic reasoning

Organisations

• Home of Medicine Podcast
• Royal College of Physicians Edinburgh
• Lincoln Medical School

Clinical Concepts

• Chronic back pain flare-up management
• Lumbar radiculopathy
• Multi-level disc degeneration
• Cauda equina syndrome (differential)
• Osteoporotic fracture (differential)
• Opioid stewardship / opioid-induced hyperalgesia
• C-reactive protein (CRP) as an inflammatory marker
• Discitis (spinal infection — discussed as a differential diagnosis)
• Cellulitis
• Herpes zoster (shingles) as a back pain mimic
• Pretest probability
• Hickam's dictum
• Premature closure (cognitive bias)
• Satisficing (cognitive bias)
• Shared decision-making
• Cyclical vomiting syndrome (comparator example)

Medications

• Gabapentin
• Amitriptyline
• Oromorph / morphine
• Morphine sulfate tablets (MST)
• Flucloxacillin
• DOAC (direct oral anticoagulant, referenced as a comparator example)

Diagnostic Tools

• MRI spine
• Full blood count / neutrophils
• Alkaline phosphatase (ALP)
• Neurological examination