Lower back pain
Cause Patient Onset Radiation Exam Evaluation Treatment Fracture Malignancy
Osteoporosis
Acute-subacute Rare Localized pain xray Pain meds
Refer/admit
Malignancy Hx of cancer
Age > 50
Pain > 1 mo
Incr. severity
Subacute Yes with epidural mets +/- decr neuro xray
ESR
MRI/CT-M
Steroids
Admit
Infection Immunocomp
IVDA
Children
Subacute Yes with epidural abscess +/- decr neuro
Localized pain
Fever in 50%
xray
ESR
MRI/CT-M
Abx
Neurosx consult
Musc/skel Adults Acute-subacute
Yes if herniated disc +/- decr neuro
+ SLR
Nothing
xrays?
CT/MRI?
Pain meds
Modified activity
Referral
Cauda Equ Adults-elderly Acute-subacute Bilateral S/S
Urine/fecal changes
Decr rectal tone
Saddle anesthesia
MRI/CT-M Neurosx
Work-Up
0) Icon
1) X-rays* (if have red flag)
2) CBC/ESR/Chem 7/UA (if >50 yo)
3) Abd aorta US (if susp AAA >60 yo)
4) Pain treatment
- X-RAYS
Adults: AP & lateral of lumbar spine
Children: add oblique views (to evaluate for spondolithesis)
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)