Lower back pain

Causes

Cause	Patient	Onset	Radiation	Exam	Evaluation	Treatment
Fracture	Malignancy Osteoporosis	Acute-subacute	Rare	Localized pain	x-ray	Pain meds Refer/admit
Malignancy	Hx of cancer Age > 50 Pain > 1 mo Incr. severity	Subacute	Yes with epidural mets	+/- decr neuro	x-ray ESR MRI/CT-M	Steroids Admit
Infection	Immunocomp IVDA Children	Subacute	Yes with epidural abscess	+/- decr neuro Localized pain Fever in 50%	x-ray ESR MRI/CT-M	Abx Neurosx consult
Musc/skel	Adults	Acute-subacute	Yes if herniated disc	+/- decr neuro + SLR	Nothing x-rays? CT/MRI?	Pain meds Modified activity Referral
Cauda Equina	Adults-elderly	Acute-subacute	Bilateral S/S Urine/fecal changes Decr rectal tone Saddle anesthesia		MRI/CT-M	Neurosx

Work-Up

1. Pregnancy test
2. Straight leg raise testing
   1. True sciatic tension should elicit pain before the hamstrings are stretched enough to move the plevis
3. X-rays* (if have red flag)
   1. Adults: AP + lateral of lumbar spine
   2. Children: add oblique views (to evaluate for spondylolisthesis)
4. Labs
   1. CBC/ESR/Chem 7/UA (if >50 yo)
5. US
   1. Rule-out AAA

CT/MRI INDICATIONS

1. Suspect disc dis. w. severe motor impairment,
2. Suspect abcess or mets w/ neuro involv.
3. Cauda equina syndrome.
4. Elevated ESR

Red Flags

• See Back Pain (Red Flags)

DDX

• AAA
• Cauda equina syndrome
• Epidural abcess/hematoma
• Spinal fracture with cord/nerve impingement
• Back pain with neurologic def
• Intervetebral disk herniation
• Cancer
• Meningitis
• Sciatica
• Spinal fracture
• Spinal stenosis
• Transverse myelitis
• Vertebral osteo
• Acute ligamentous injury
• Acute muscle strain
• Ankylosing spondylitis
• Degeverative joint disease
• Intervetebral disk disase
• Pathologic fracture
• Seropositive arthritis
• Spondylolithesis
• Cholecystitis
• Esophageal disease
• Pleural effusion
• Pancreatic disease
• Ulcer perforation
• Retrocecal appendicitis
• Large bowel obstruction
• Renal disease
• Pelvic disease
• PID
• Nephrolithiasis
• PNA
• PE
• Pyelonephritis
• Retroperitoneal hemorrhage/mass

Cord Compression

L4: pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk.

L5: pain side leg, wk dorsiflex, sens. loss lat lo leg & web big toe, reflex intact.

S1: pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.

-Straight leg raise most sens., crossed most specific.

-Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.

-Sciatica: impinged or irritated nerve. radicular distr., sharp, NO paresthesias/pain distal to knee/neuro impairment.

-Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief.

Treatment (Pain)

Mild to mod:

-NSAIDs

Mod to Severe

-non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN

-OPIOD (vicodin or percocet) & nonsteroidal for 2-3 dy, then NSAID alone.

-#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril)

-Bedrest 2-3 days

-Referral

See Also

Back Pain (Red Flags)

Source

1/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)