Lower back pain: Difference between revisions
No edit summary
Line 1: Line 1:
== Causes ==
== Causes ==


{| style="width: 479px; height: 436px" border="1" cellpadding="1"
{| style="width: 479px; height: 436px" border="1" cellpadding="1"
|-
|-
| '''Cause'''
| '''Cause'''  
| '''Patient'''
| '''Patient'''  
| '''Onset'''
| '''Onset'''  
| '''Radiation'''
| '''Radiation'''  
| '''Exam'''
| '''Exam'''  
| '''Evaluation'''
| '''Evaluation'''  
| '''Treatment'''
| '''Treatment'''
|-
|-
| Fracture
| Fracture  
|  
|  
Malignancy
Malignancy  


Osteoporosis
Osteoporosis  


| Acute-subacute
| Acute-subacute  
| Rare
| Rare  
| Localized pain
| Localized pain  
| xray
| x-ray
|  
|  
Pain meds
Pain meds  


Refer/admit
Refer/admit  


|-
|-
| Malignancy
| Malignancy  
|  
|  
Hx of cancer
Hx of cancer  


Age > 50
Age > 50  


Pain > 1 mo
Pain > 1 mo  


Incr. severity
Incr. severity  


| Subacute
| Subacute  
| Yes with epidural mets
| Yes with epidural mets  
| +/- decr neuro
| +/- decr neuro  
|  
|  
xray
x-ray


ESR
ESR  


MRI/CT-M
MRI/CT-M  


|  
|  
Steroids
Steroids  


Admit
Admit  


|-
|-
| Infection
| Infection  
|  
|  
Immunocomp
Immunocomp  


IVDA
IVDA  


Children
Children  


| Subacute
| Subacute  
| Yes with epidural abscess
| Yes with epidural abscess  
|  
|  
+/- decr neuro
+/- decr neuro  


Localized pain
Localized pain  


Fever in 50%
Fever in 50%  


|  
|  
xray
x-ray


ESR
ESR  


MRI/CT-M
MRI/CT-M  


|  
|  
Abx
Abx  


Neurosx consult
Neurosx consult  


|-
|-
| Musc/skel
| Musc/skel  
| Adults
| Adults  
|  
|  
Acute-subacute
Acute-subacute  


| Yes if herniated disc
| Yes if herniated disc  
|  
|  
+/- decr neuro
+/- decr neuro  


+ SLR
+ SLR  


|  
|  
Nothing
Nothing  


xrays?
x-rays?  


CT/MRI?
CT/MRI?  


|  
|  
Pain meds
Pain meds  


Modified activity
Modified activity  


Referral
Referral  


|-
|-
| Cauda Equ
| Cauda Equina
| Adults-elderly
| Adults-elderly  
| Acute-subacute
| Acute-subacute  
| colspan="2" |  
| colspan="2" |  
Bilateral S/S
Bilateral S/S  


Urine/fecal changes
Urine/fecal changes  


Decr rectal tone
Decr rectal tone  


Saddle anesthesia
Saddle anesthesia  


| MRI/CT-M
| MRI/CT-M  
| Neurosx
| Neurosx
|}
|}


== Work-Up ==
== Work-Up ==
#Pregnancy test
# X-rays* (if have red flag)
##Adults: AP & lateral of lumbar spine
##Children: add oblique views (to evaluate for spondolithesis)
# CBC/ESR/Chem 7/UA (if >50 yo)
# Abd aorta US (if susp AAA >60 yo)
# Pain treatment


===CT/MRI INDICATIONS===
#Pregnancy test
#Suspect disc dis. w. severe motor impairment,
#Straight leg raise
#Suspect abcess or mets w/ neuro involv.
#X-rays* (if have red flag)
#Cauda equina syndrome.
##Adults: AP & lateral of lumbar spine
##Children: add oblique views (to evaluate for spondolithesis)
#CBC/ESR/Chem 7/UA (if >50 yo)
#Abd aorta US (if susp AAA >60 yo)
#Pain treatment
 
=== CT/MRI INDICATIONS ===
 
#Suspect disc dis. w. severe motor impairment,  
#Suspect abcess or mets w/ neuro involv.  
#Cauda equina syndrome.  
#Elevated ESR
#Elevated ESR


== Red Flags ==
== Red Flags ==
 
History


History
-Pain >4 weeks


-Pain >4 weeks
-Age >50 or <18


-Age >50 or <18
-History of trauma


-History of trauma
-Bilateral sciatica (or LBP w/ new sciatica)


-Bilateral sciatica (or LBP w/ new sciatica)
-Neurologic complaints


-Neurologic complaints
-Bladder/bowel incontinence


-Bladder/bowel incontinence
-Night pain


-Night pain
-Unrelenting pain despite rest and analgesics


-Unrelenting pain despite rest and analgesics
-Fevers/chills/nightsweats


-Fevers/chills/nightsweats
-IVDA history


-IVDA history
-Hx of cancer


-Hx of cancer
-Prolonged steriod use


-Prolonged steriod use
-Unexplained weight loss


-Unexplained weight loss
Physical Exam


Physical Exam
-Fever


-Fever
-Point vertebral tenderness


-Point vertebral tenderness
-Neurologic deficits


-Neurologic deficits
-?Patient writhing in pain


-?Patient writhing in pain
== DDX  ==


== DDX ==
AAA


AAA
Cauda equina sy


Cauda equina sy
Epidural abcess/hematoma


Epidural abcess/hematoma
Spinal fracture with cord/nerve impingement


Spinal fracture with cord/nerve impingement
Back pain with neurologic def


Back pain with neurologic def
Intervetebral disk herniation


Intervetebral disk herniation
CA


CA
Meningitis


Meningitis
Siatica


Siatica
Spinal fracture


Spinal fracture
Spinal stenosis


Spinal stenosis
Transverse myelitis


Transverse myelitis
Vertebral osteo


Vertebral osteo
Acute ligamentous injury


Acute ligamentous injury
Acute muscle strain


Acute muscle strain
Ankylosing spondylitis


Ankylosing spondylitis
Degeverative joint disease


Degeverative joint disease
Intervetebral disk disase


Intervetebral disk disase
Pathologic fracture


Pathologic fracture
Seropositive arthritis


Seropositive arthritis
Spondylolithesis


Spondylolithesis
Cholecystitis


Cholecystitis
Esophageal dz


Esophageal dz
Pleural effusion


Pleural effusion
Pancreatic dis.


Pancreatic dis.
Perffed ulcer


Perffed ulcer
Retrocecal appy


Retrocecal appy
Large bowel obstr.


Large bowel obstr.
Renal dz


Renal dz
Pelvic dz  


Pelvic dz
PID


PID
Nephrolithiasis


Nephrolithiasis
PNA


PNA
PE


PE
Pyelonephritis


Pyelonephritis
Retroperitoneal hemorrhage/mass


Retroperitoneal hemorrhage/mass
== Cord Compression  ==


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


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 &amp; web big toe, reflex intact.  


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.  


S1: pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.
-Straight leg raise most sens., crossed most specific.  


-Straight leg raise most sens., crossed most specific.
-Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.  


-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.  


-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.  


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


== Treatment (Pain) ==
Mild to mod:


Mild to mod:
-NSAIDs


-NSAIDs
Mod to Severe


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


-non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN
-OPIOD (vicodin or percocet) &amp; nonsteroidal for 2-3 dy, then NSAID alone.


-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)


-#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


-Bedrest 2-3 days
-Referral


-Referral
== See Also  ==


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


== Source ==
== Source ==


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


[[Category:Ortho]]
[[Category:Ortho]]

Revision as of 00:57, 18 February 2012

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
  3. X-rays* (if have red flag)
    1. Adults: AP & lateral of lumbar spine
    2. Children: add oblique views (to evaluate for spondolithesis)
  4. CBC/ESR/Chem 7/UA (if >50 yo)
  5. Abd aorta US (if susp AAA >60 yo)
  6. Pain treatment

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

History

-Pain >4 weeks

-Age >50 or <18

-History of trauma

-Bilateral sciatica (or LBP w/ new sciatica)

-Neurologic complaints

-Bladder/bowel incontinence

-Night pain

-Unrelenting pain despite rest and analgesics

-Fevers/chills/nightsweats

-IVDA history

-Hx of cancer

-Prolonged steriod use

-Unexplained weight loss

Physical Exam

-Fever

-Point vertebral tenderness

-Neurologic deficits

-?Patient writhing in pain

DDX

AAA

Cauda equina sy

Epidural abcess/hematoma

Spinal fracture with cord/nerve impingement

Back pain with neurologic def

Intervetebral disk herniation

CA

Meningitis

Siatica

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 dz

Pleural effusion

Pancreatic dis.

Perffed ulcer

Retrocecal appy

Large bowel obstr.

Renal dz

Pelvic dz

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)

Retrieved from "https://www.wikem.org/w/index.php?title=Lower_back_pain&oldid=8024"