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]
Clinical Features
|
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
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
- Spine related
- Renal disease
- Intra-abdominal
- 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?
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
- Plain films
- MRI
- Ultrasound
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
- 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
- Treatment is the same as for musculoskeletal back pain
- Immediate Ortho referral for spinal decompression to avoid permanent bowel/bladder injury
Disposition
- Normally outpatient, as long as no signs of emergent pathology and able to ambulate
See Also
External Links
Video
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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.