Lower back pain

Background

• Pain lasting >6wk is risk factor for more serious disease

Clinical Features

• Musculoskeletal pain
  • Located primarily in the back w/ possible radiation into the buttock/thighs
• Sciatica
  • Refers to radicular back pain in the distribution of a lumbar or sacral nerve root
  • Often accompanied by sensory or motor deficits
  • Occurs in only 1% of pts w/ back pain
  • 95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces

Work-Up

1. Pregnancy test
2. Straight leg raise testing
   1. True sciatic tension should elicit pain before 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 disk disease w/ severe motor impairment
2. Suspect abcess or mets w/ neuro involvement
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

• 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)