Lower back pain

Background

• Pain lasting >6wks is risk factor for more serious disease
• Back pain in IV drug user is spinal infection until proven otherwise
• Night pain and unrelenting pain are worrisome symptoms

Clinical Features

• See Back Pain (Red Flags)
• Musculoskeletal pain
  • Located primarily in the back w/ possible radiation into the buttock/thighs
  • Pain worse w/ movement but improves w/ rest
• Spinal stenosis
  • Bilateral sciatic pain worsened by walking, prolonged standing; relieved by forward flexion
• Sciatica
  • Refers to radicular back pain in the distribution of a lumbar or sacral nerve root
  • Pain worsened by coughing, Valsalva, sitting; relieved by lying in supine position
  • Occurs in only 1% of pts w/ back pain
  • 95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces

DDX

• See Back Pain (DDX)

Work-Up

1. Pregnancy test
2. Exam
   1. Straight leg raise testing
      1. Screening exam for a herniated disk (Sn 68-80%)
      2. Lifting leg causes radicular pain of affected leg radiating to BELOW the knee
      3. Pain is worsened by ankle dorsiflexion
   2. Crossed Straight leg raise testing (high Sp, low Sn)
      1. Lifting the asymptomatic leg causes radicular pain down the affected leg
   3. Nerve root compromise
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. MRI
   1. Indications:
      1. 1. Suspect disk disease w/ severe motor impairment
         2. Suspect abscess or metastases w/ neuro involvement
6. Cauda equina syndrome
7. ?Elevated ESR
8. US
   1. Rule-out AAA

See Also

• Back Pain (Red Flags)
• See Back Pain (DDX)

Source

• Tintinalli