I have lower and upper back pain for the past two years. Please help.

Question

Hello doctor,

For the last two years, I have back pain in the upper and lower region. I am uploading here with my reports for your reference. Please suggest diagnosis and medicines to cure this disease.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your reports. (attachment removed to protect patient identity). I would like to ask you a few more queries to see where your disease is heading for. We do have a limitation of clinical examination, but I would do my best to guide you here. When is the pain more? Is it the morning time or constant throughout the day? Do you have difficulty in turning position at night? Any family history of similar complaints? Any history of redness of the eyes or disturbed bowel habits? Do you wake up well in the morning or do you feel your body is stiff? Do let me know these queries. As per your lab reports, most of them are fine except for a couple of things.

1. CRP (C-reactive protein) levels are not done which are important markers for arthritis.

2. HLA-B27 (human leucocyte antigen) has been done by an outdated technique. We prefer doing it by PCR. Nevertheless, let me know these queries and I would guide you to the next best investigation.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

Well, as per your clinical symptoms it looks more of a degenerative disease than an inflammatory one. When it comes to the spine, we approach it in two ways. Either there is a lot of inflammation for which you got the test done but it does not match your symptoms. Another way is the disc problem or the nerve problem. I would suggest you go for an MRI (magnetic resonance imaging) of the whole spine along with the focus on dedicated parts where there is a problem. Also meanwhile get a physiotherapist to help you as they will speed up the recovery part.

Once you have the MRI do let me know and we can plan further treatment for you.