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
- Pregnancy test
- Straight leg raise testing
- True sciatic tension should elicit pain before the hamstrings are stretched enough to move the plevis
- X-rays* (if have red flag)
- Adults: AP + lateral of lumbar spine
- Children: add oblique views (to evaluate for spondylolisthesis)
- Labs
- CBC/ESR/Chem 7/UA (if >50 yo)
- US
- Rule-out AAA
CT/MRI INDICATIONS
- Suspect disc dis. w. severe motor impairment,
- Suspect abcess or mets w/ neuro involv.
- Cauda equina syndrome.
- Elevated ESR
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
Source
1/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)