Lower back pain: Difference between revisions
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*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]] | ||
{{Waddell's Signs of Non-Organic Back Pain}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Lower back pain DDX}} | {{Lower back pain DDX}} | ||
== | ==Evaluation== | ||
===Exam=== | ===Exam=== | ||
*Straight leg raise testing | *Straight leg raise testing | ||
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**CBC, UA, ESR (90-98% Sn for infectious etiology) | **CBC, UA, ESR (90-98% Sn for infectious etiology) | ||
*Consider post void residual | *Consider post void residual | ||
**Can be done with non invasively with [[ | **Can be done with non invasively with [[Bladder ultrasound|Ultrasound]] | ||
===Imaging=== | ===Imaging=== | ||
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**Consider for back pain >6-8wks | **Consider for back pain >6-8wks | ||
*Ultrasound | *Ultrasound | ||
**Rule-out [[ | **Rule-out [[Aortic ultrasound|AAA]] | ||
== | ==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|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]] 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) | ||
** | |||
** | |||
* | |||
** | |||
*[[ | |||
** | |||
==See Also == | ====Not Indicated==== | ||
*[[Benzodiazepines]] | |||
**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> | |||
*[[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> | |||
===Acute, Radicular Back Pain (Sciatica)=== | |||
''80% of patients will ultimately improve without surgery'' | |||
*Treatment is mostly the same as for acute non-radicular back pain | |||
*Consider also [[gabapentin]] (titrate slowly) or [[TCAs]] ([[nortriptyline]], [[amytriptyline]]) | |||
**[[Gabapentin]] Oral: Immediate release: 400mg-1200mg PO TID | |||
===[[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== | |||
*[[Back Pain (Red Flags)]] | *[[Back Pain (Red Flags)]] | ||
==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) |
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
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
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?
- To rule out cauda equina syndrome
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
- Can be done with non invasively with Ultrasound
Imaging
- Plain films
- Only necessary if suspect fracture, tumor, or infection
- Part of ACEP Choosing wisely
- MRI
- Only necessary if suspect infection, neoplasm, epidural compression syndromes
- Consider for back pain >6-8wks
- Ultrasound
- Rule-out AAA
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)
- Acetaminophen and/or NSAIDs
Not Indicated
Acute, Radicular Back Pain (Sciatica)
80% of patients will ultimately improve without surgery
- Treatment is mostly the same as for acute non-radicular back pain
- Consider also gabapentin (titrate slowly) or TCAs (nortriptyline, amytriptyline)
- Gabapentin Oral: Immediate release: 400mg-1200mg PO TID
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
- ↑ 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]
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
- ↑ Waddell G, et al. Non-organic physical signs in low-back pain. Spine. 1980; 5:117-125.
- ↑ 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
- ↑ 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
- ↑ Holve, RL, et al. Oral steroids in initial treatment of acute sciatica. J Am Board Fam Med. 2008; 21(5):469-474.
- ↑ 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.