Lower back pain: Difference between revisions

(Text replacement - "OR" to "'''OR'''")
(21 intermediate revisions by 7 users not shown)
Line 5: Line 5:
*95% of herniated discs occur at L4-L5 or L5-S1 (for both pain extends below the knee)
*95% of herniated discs occur at L4-L5 or L5-S1 (for both pain extends below the knee)
*Lumbago: acute, nonspecific back pain
*Lumbago: acute, nonspecific back pain
{{Back pain red flags}}


==Clinical Features==
==Clinical Features==
{{Symptoms by Causes of Back Pain}}
[[File:Lumbar_Nerve_Root_Compromise.jpg|thumb|Lumbar nerve root distribution]]
[[File:Lumbar_Nerve_Root_Compromise.jpg|thumb|Lumbar nerve root distribution]]
*Musculoskeletal pain
**Located primarily in the back with possible radiation into the buttock/thighs
**Pain worse with movement but improves with rest
*Spinal stenosis
**Bilateral sciatic pain worsened by walking (pseudo-claudication), prolonged standing
**Pain relieved by forward flexion, especially sitting
*Sciatica
**Radicular back pain in the distribution of a lumbar or sacral nerve root
***Anything that compresses the nerve roots, cauda equina, or cord can cause sciatica
**Pain worsened by coughing, Valsalva, sitting; relieved by lying in supine position
**Occurs in only 1% of patients with back pain
**Present in 95% of patients who have a symptomatic herniated disk
*Urinary/bowel disturbances, perineal anaesthesia
**Cauda equina syndrome, due to compression of spinal nerve roots
**Ortho emergency!
*Inflammatory back pain
**Morning stiffness >30minutes
**Consider seronegative spondyloarthropathies, especially if in young adults (eg ankylosing spondylitis, psoriatic arthropathy, IBD arthropathy, Reiter's disease)
{{Back pain red flags}}


===Waddell's Signs of Non-Organic Back Pain===
{{Waddell's Signs of Non-Organic Back Pain}}
*Assess for the following<ref>Waddell G, et al. Non-organic physical signs in low-back pain. Spine. 1980; 5:117-125.</ref>:
*#Over-reaction to the examination
*#Widespread superficial tenderness not corresponding to any anatomical distribution
*#Pain on axial loading of the skull or pain on rotation of the shoulders and pelvis together
*#Severely limited straight leg raising on formal testing in a patient who can sit forwards with the legs extended
*#Lower limb weakness or sensory loss not corresponding to a nerve root distribution
*3 or more positives suggest non-organic or alternative organic source


==Differential Diagnosis==
==Differential Diagnosis==
Line 73: Line 49:


==Management==
==Management==
===Nonspecific Back Pain (musculoskeletal)===
===Acute, Non-traumatic, Non-Radicular Back Pain===
*Instruct to continue daily activities using pain as limiting factor
*Instruct to continue daily activities using pain as limiting factor
*Medications
*Medications
**[[Acetaminophen]]
**[[Acetaminophen]] and/or [[NSAIDs]]
**[[NSAIDs]]
***1st line therapy
***1st line therapy
***Consider gel/patch like [[Diclofenac|diclofenac]] or [[Ketoprofen|ketoprofen]] (shown to be more effective than PO form and placebo in one study<ref>Mazières B, Rouanet S, Velicy J, et al. Topical ketoprofen patch (100 mg) for the treatment of ankle sprain: a randomized, double-blind, placebo-controlled study. Am J Sports Med. 2005;33:515-523</ref>)
***Consider gel/patch like [[Diclofenac|diclofenac]] or [[Ketoprofen|ketoprofen]] (shown to be more effective than PO form and placebo in one study<ref>Mazières B, Rouanet S, Velicy J, et al. Topical ketoprofen patch (100 mg) for the treatment of ankle sprain: a randomized, double-blind, placebo-controlled study. Am J Sports Med. 2005;33:515-523</ref>)
**[[Lidocaine Patches]]
**[[Lidocaine]] patch
**Capsaicin or Cayenne
**[[Capsaicin]] or Cayenne
***Skin desensitization upon repeated exposure
***Skin desensitization upon repeated exposure
**Muscle relaxants (limited evidence)
***cyclobenzaprine 10 mg PO OR
***methocarbamol 1500 mg PO
**[[Opioids]]
**[[Opioids]]
***Appropriate for moderate-severe pain but only for limited duration (1-2wks)
***Appropriate for moderate-severe pain but only for limited duration (<1 week)
**Muscle relaxants
 
***Efficacy appears equal to NSAIDs
====Not Indicated====
***[[Diazepam]] 5-10mg PO q6-8hr '''OR''' methocarbamol 1000-1500mg PO QID
*[[Benzodiazepines]]
**[[Steroids]] (of questionable effectiveness<ref>Holve, RL, et al. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008; 21(5):469-474. </ref><ref>Goldberg H, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. PMID 25988461.</ref>)
**No benefit over [[NSAIDs]] alone<ref>Friedman BW, et al. "Diazepam is no better than placebo when added to Naproxen for acute low back pain." Annals of EM. August 2017. 70(2):169-176</ref>
***[[Prednisone]] 40-60mg PO qd x 5-10 days
*[[Steroids]]  
**Of unlikely effectiveness<ref>Holve, RL, et al. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008; 21(5):469-474. </ref><ref>Goldberg H, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. PMID 25988461.</ref>


===Sciatica===
===Acute, Radicular Back Pain (Sciatica)===
*Treatment is the same as for musculoskeletal back pain
''80% of patients will ultimately improve without surgery''
*80% of patients will ultimately improve without surgery
*Treatment is mostly the same as for acute non-radicular back pain
*Primary care provider should consider AEDs (gapapentin, titrate slowly) or [[TCAs]] (nortriptyline, amytriptyline)
*Consider also [[gabapentin]] (titrate slowly) or [[TCAs]] ([[nortriptyline]], [[amytriptyline]])
**[[Gabapentin]] Oral: Immediate release: 400mg-1,200mg PO TID
**[[Gabapentin]] Oral: Immediate release: 400mg-1200mg PO TID


===[[Spinal stenosis]]===
===[[Spinal stenosis]]===
Line 101: Line 80:


===[[Cauda equina syndrome]]===
===[[Cauda equina syndrome]]===
*Immediate Ortho referral for spinal decompression to avoid permanent bowel/bladder injury
*Immediate spine surgery consultation for spinal decompression to avoid permanent bowel/bladder/neurologic injury


==Disposition==
==Disposition==
Line 111: Line 90:
==External Links==
==External Links==
*[http://ddxof.com/back-pain/ DDxOf: Differential Diagnosis of Back Pain]
*[http://ddxof.com/back-pain/ DDxOf: Differential Diagnosis of Back Pain]
==Video==
{{#widget:YouTube|id=vdrrzay7EOk}}


==References==
==References==

Revision as of 17:31, 1 October 2020

Background

  • Pain lasting >6wks is risk factor for more serious disease
  • Night pain and unrelenting pain are worrisome symptoms
  • Back pain in IV drug user is spinal infection until proven otherwise
  • 95% of herniated discs occur at L4-L5 or L5-S1 (for both pain extends below the knee)
  • Lumbago: acute, nonspecific back pain

Back Pain Risk factors and probability of Fracture or Malignancy[1]

Factor Post Test Probability (95%CI)
Older Age (>65yo) 9% (3-25%)
Prolonged corticosteroid 33% (10-67%)
Severe trauma 11% (8-16%)
Presence of contusion or abrasion 62% (49-74%)
Multiple red flags 90% (34-99%)
History of malignancy 33% (22-46%)

Red Flag Symptoms of Low Back Pain [2]

Symptoms Corresponding Pathology
Age under 18 years Congenital abnormality
Age over 50 years Fracture, malignancy
Anticoagulant use Spinal hematoma
Fever Infection, malignancy
Genitourinary issues including urinary retention/incontinence or sexual dysfunction Cauda equina syndrome
Immunocompromised Fracture, infection
IV drug use Infection
Recent spinal surgery or epidural injection Infection, spinal hematoma
Trauma Fracture, spinal hematoma

Red Flag Signs of Low Back Pain[3]

Signs Corresponding Pathology
Reduced anal sphincter tone Cauda equina syndrome
Hyperreflexia Acute cord compression
Hyporeflexia/areflexia Cauda equina syndrome
Lower extremity muscle weakness Acute cord compression or Cauda equina syndrome
Saddle paresthesia/anesthesia Cauda equina syndrome
Absent or decreased bulbocavernosus reflex Cauda equina syndrome

Clinical Features

Symptoms by Causes of Low back pain

Musculoskeletal pain Spinal stenosis Sciatica Cauda equina syndrome Rheumatologic
Radiation? No Possible (can be bilateral) Yes (in the distribution of a lumbar or sacral nerve root) Possible ?
Worsened by: Movement (e.g. twisting of torso) Walking (pseudo-claudication) and prolonged standing Coughing, Valsalva, sitting Morning stiffness >30minutes
Improved by: Rest Forward flexion, especially sitting Lying in supine position Movement throughout the day
Other symptoms: Urinary/bowel disturbances, perineal anaesthesia Other rheum symptoms (e.g. ankylosing spondylitis, psoriatic arthropathy, IBD arthropathy, Reiter's disease)
Lumbar nerve root distribution

Waddell's Signs of Non-Organic Low back pain[4]

3 or more positives suggest non-organic or alternative organic source:

  • Over-reaction to the examination
  • Widespread superficial tenderness not corresponding to any anatomical distribution
  • Pain on axial loading of the skull or pain on rotation of the shoulders and pelvis together
  • Severely limited straight leg raising on formal testing in a patient who can sit forwards with the legs extended
  • Lower limb weakness or sensory loss not corresponding to a nerve root distribution

Differential Diagnosis

Differential diagnosis of back pain

Lower Back Pain

Evaluation

Exam

  • Straight leg raise testing
    • Screening exam for a herniated disk (Sn 68-80%)
    • Lifting leg causes radicular pain of affected leg radiating to BELOW the knee
    • Pain is worsened by ankle dorsiflexion
    • Pain may be relieved by pressing across biceps femoris and pes anserinus tendons behind knee ('bowstringing')
  • Crossed Straight leg raise testing (high Sp, low Sn)
    • Lifting the asymptomatic leg causes radicular pain down the affected leg
  • Nerve root compromise
  • Rectal exam, perineal sensation, palpable bladder?

Labs

  • Pregnancy test
  • Only necessary if concerned for infection, tumor, or rheumatologic cause
    • CBC, UA, ESR (90-98% Sn for infectious etiology)
  • Consider post void residual

Imaging

Management

Acute, Non-traumatic, Non-Radicular Back Pain

  • Instruct to continue daily activities using pain as limiting factor
  • Medications
    • Acetaminophen and/or NSAIDs
      • 1st line therapy
      • Consider gel/patch like diclofenac or ketoprofen (shown to be more effective than PO form and placebo in one study[5])
    • Lidocaine patch
    • Capsaicin or Cayenne
      • Skin desensitization upon repeated exposure
    • Muscle relaxants (limited evidence)
      • cyclobenzaprine 10 mg PO OR
      • methocarbamol 1500 mg PO
    • Opioids
      • Appropriate for moderate-severe pain but only for limited duration (<1 week)

Not Indicated

Acute, Radicular Back Pain (Sciatica)

80% of patients will ultimately improve without surgery

Spinal stenosis

  • Treatment is the same as for musculoskeletal back pain

Cauda equina syndrome

  • Immediate spine surgery consultation for spinal decompression to avoid permanent bowel/bladder/neurologic injury

Disposition

  • Normally outpatient, as long as no signs of emergent pathology and able to ambulate

See Also

External Links

Video

{{#widget:YouTube|id=vdrrzay7EOk}}

References

  1. ↑ Downie A, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013; 347:f7095. [1]
  2. ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
  3. ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
  4. ↑ Waddell G, et al. Non-organic physical signs in low-back pain. Spine. 1980; 5:117-125.
  5. ↑ Mazières B, Rouanet S, Velicy J, et al. Topical ketoprofen patch (100 mg) for the treatment of ankle sprain: a randomized, double-blind, placebo-controlled study. Am J Sports Med. 2005;33:515-523
  6. ↑ Friedman BW, et al. "Diazepam is no better than placebo when added to Naproxen for acute low back pain." Annals of EM. August 2017. 70(2):169-176
  7. ↑ Holve, RL, et al. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008; 21(5):469-474.
  8. ↑ Goldberg H, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. PMID 25988461.
Retrieved from "https://www.wikem.org/w/index.php?title=Lower_back_pain&oldid=276645"