View source for Lower back pain

==Background==
*May also be called lumbago, referring to pain in the muscles and joints of the lower back
*Pain lasting > 6 weeks is risk factor for more serious disease
*Night pain and unrelenting pain are worrisome symptoms
*Back pain in IV drug user is spinal infection until proven otherwise
*95% of herniated discs occur at L4-L5 or L5-S1 (for both pain extends below the knee)

{{Back pain red flags}}

==Clinical Features==
{{Symptoms by Causes of Back Pain}}
[[File:Lumbar_Nerve_Root_Compromise.jpg|thumb|Lumbar nerve root distribution]]

{{Waddell's Signs of Non-Organic Back Pain}}

==Differential Diagnosis==
[[File:Back_Pain.png|thumb|Differential diagnosis of back pain]]
{{Lower back pain DDX}}

==Evaluation==
===Exam===
*Straight leg raise testing
**Screening exam for a herniated disk (Sn 68-80%)
**Lifting leg causes radicular pain of affected leg radiating to BELOW the knee
**Pain is worsened by ankle dorsiflexion
**Pain may be relieved by pressing across biceps femoris and pes anserinus tendons behind knee ('bowstringing')
*Crossed Straight leg raise testing (high Sp, low Sn)
**Lifting the asymptomatic leg causes radicular pain down the affected leg
*Nerve root compromise
*Rectal exam, perineal sensation, palpable bladder?
**To rule out [[cauda equina syndrome]]

===Labs===
*Pregnancy test 
*Only necessary if concerned for infection, tumor, or rheumatologic cause
**CBC, UA, ESR (90-98% Sn for infectious etiology)
*Consider post void residual
**Can be done with non invasively with [[Bladder ultrasound|Ultrasound]]

===Imaging===
*Multiple institutions advise '''against''' routine initial imaging of the lumbar spine in adults with acute non-traumatic low back pain, in the absence of severe progressive neurologic deficit, absence of red flags, and if <6 weeks in duration.<ref>ACEP - Lumbar spine imaging in the ED | Choosing Wisely. October 27, 2014. Accessed March 30, 2023. https://www.choosingwisely.org/clinician-lists/acep-lumbar-spine-imaging-in-the-ed/</ref><ref>American College of Physicians. Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. February 24, 2015. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-college-of-physicians/</ref><ref>American Academy of Family Physicians. Twenty Things Physicians and Patients Should Question. Choosing Wisely Campaign. 2021. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-academy-of-family-physicians/</ref><ref>American Society of Anesthesiologists. Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. Published 2019. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-society-of-anesthesiologists-pain-medicine/</ref><ref>American College of Occupational and Environmental Medicine. Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. Published 2022. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-college-of-occupational-and-environmental-medicine/</ref><ref>American Association of Neurological Surgeons and Congress of Neurological Surgeons. Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. Published June 24, 2014. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-association-of-neurological-surgeons-and-congress-of-neurological-surgeons/</ref><ref>American Chiropractic Association. Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. Published 2021. Accessed March 10, 2023. https://www.choosingwisely.org/societies/american-chiropractic-association/</ref><ref>Five Things Physicians and Patients Should Question. Choosing Wisely Campaign. Published 2022. Accessed March 10, 2023. https://www.choosingwisely.org/societies/north-american-spine-society/</ref>
**Part of [[Choosing wisely ACEP|ACEP Choosing wisely ]]

*Plain films
**May consider if suspect fracture, tumor, or infection, however, of low utility. 
*CT
**Better for identification of fractures. 
*MRI
**Only necessary if suspect infection, neoplasm, [[epidural compression syndromes]]
**Consider for back pain >6-8wks, progressive neurologic deficit, or presence of red flags
**'''Gold Standard:''' if [[cauda equina syndrome]] is suspected
*Ultrasound
**Rule-out [[Aortic ultrasound|AAA]]

==Management==
===Acute, Non-traumatic, Non-Radicular Back Pain===
*Instruct to continue daily activities using pain as limiting factor
*Recommend at home stretches
*Medications
**[[Acetaminophen]] and/or [[NSAIDs]]
***1st line therapy
***Consider gel/patch like [[Diclofenac|diclofenac]] or [[Ketoprofen|ketoprofen]] (shown to be more effective than PO form and placebo in one study<ref>Mazières B, Rouanet S, Velicy J, et al. Topical ketoprofen patch (100 mg) for the treatment of ankle sprain: a randomized, double-blind, placebo-controlled study. Am J Sports Med. 2005;33:515-523</ref>)
**[[Lidocaine]] patch
**[[Capsaicin]] or Cayenne
***Skin desensitization upon repeated exposure
**Muscle relaxants (limited evidence)
***Cyclobenzaprine 10 mg PO OR
***Methocarbamol 1500 mg PO
**[[Opioids]]
***Can be considered for moderate-severe pain but only for limited duration (<1 week)
***Associated with higher return rates to ED within 30 days for same complaint when compared to other modalities

====Not Indicated====
*[[Steroids]] 
**Of unlikely effectiveness<ref>Holve, RL, et al. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008; 21(5):469-474. </ref><ref>Goldberg H, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. PMID 25988461.</ref>
*[[Benzodiazepines]]
**No benefit over [[NSAIDs]] alone<ref>Friedman BW, et al. "Diazepam is no better than placebo when added to Naproxen for acute low back pain." Annals of EM. August 2017. 70(2):169-176</ref>

===Acute, Radicular Back Pain (Sciatica)===
''80% of patients will ultimately improve without surgery''
*Treatment is mostly the same as for acute non-radicular back pain
*Consider also [[gabapentin]] (titrate slowly) or [[TCAs]] ([[nortriptyline]], [[amytriptyline]])
**[[Gabapentin]] Oral: Immediate release: 400mg-1200mg PO TID

===[[Spinal stenosis]]===
*Treatment is the same as for musculoskeletal back pain

===[[Cauda equina syndrome]]===
*Immediate spine surgery consultation for spinal decompression to avoid permanent bowel/bladder/neurologic injury
*Most common in young men<ref>Rider LS, Marra EM. Cauda Equina And Conus Medullaris Syndromes. In: StatPearls. StatPearls Publishing; 2023. Accessed March 29, 2023. http://www.ncbi.nlm.nih.gov/books/NBK537200/</ref>
*The onset of perineal anesthesia associated with bladder dysfunction is typical of the start of cauda equina syndrome and the time at which the clock starts on diagnosis and management.<ref>Quaile A. Cauda equina syndrome-the questions. Int Orthop. 2019;43(4):957-961. doi:10.1007/s00264-018-4208-0</ref>
*Painless urinary retention often has the greatest predictive value as a stand-alone symptom, but it is unfortunately indicative of late, often irreversible cauda equina syndrome<ref>Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-339. doi:10.1080/02688697.2017.1297364</ref>

==Disposition==
*Normally outpatient, as long as no signs of emergent pathology and able to ambulate

==See Also==
*[[Back Pain (Red Flags)]]

==External Links==
*[http://ddxof.com/back-pain/ DDxOf: Differential Diagnosis of Back Pain]

==References==
<references/>

[[Category:Symptoms]]
[[Category:Orthopedics]]