BACK PAIN

PATIENT CARE
1. General Information
90% of acute lower back pain will resolve in one month w/out treatment
A specific pathoanatomic diagnosis is established in less than 20% of patients
Good Review in Noble on MD Consult
MEDICAL KNOWLEDGE
1. History
Onset, radiation, location, modifying factors, etc.
Sensory or motor Sxs
Trauma Hx: fracture or disk herniation. Flexion injury leads to disk herniation
Morning stiffness relieved by exercise points to rheumatic disease
o Ask about urethritis, conjuctivits, rash, bowel habits, tick bites
Localized bone pain in elderly may point to met or MM
Sitting makes worse = disk, sitting makes better = spinal stenosis
Lying with knees flexed relieves pain = disk disease
2. Red Flag Symtpoms
Cancer: Hx, weight loss, persistence of pain, pain at night, elderly
Infection: fever, urinary Sxs, immunocompromised
Cauda Equina: urinary and anal incontinence, saddle anesthesia, bilateral lower
extremity numbness and weakness
Significant disk disease: muscle weakness and foot drop
Compression fracture: elderly, steroids, osteoporosis, MVA or fall
AAA: check for abdominal pulsing mass
3. Physical Exam
Observe: chest expansion (reduced with AS), iliac crest level, shoulder level
Check ROM and look for acute scoliosis or lordosis secondary to muscle spasm
Tendernous over spinous processes: infection or malignancy or fracture. Step off
at L5 suggests spondylolisthesis
Most important maneuver is the strait leg raise test to differentiate strain from
radiculopathy:
o Pain in radicular distribution with < 60 degrees elevation
o Ipsi = 80% sensitive but 40% specific
o Contra = 25% sensitive but 90% specific
Can also extend hip to check for L3/L4 herniation

Neuro exam of the foot including motor, sensory (light touch and proprioception)
and reflexes
o Diminished Achilles indicates L5/S1 herniation
o Walk on toes checks plantar flexion and S1
o Walk on heels checks dorsifelxion and L5
Remember dermatomes: S1 = little toe, L5 = big toe. Disk herniation gets the
lower root in the disk (i.e. L5/S1 gets S1)

4. Differential Diagnosis
Musculoskeletal: ligamentous strain, muscle strain/spasm
Disk Herniation
Compression fracture: From osteoporosis, more common in thoracic spine but can
have lumbar
Spinal Stenosis: bony encroachment from osteoarthritis on congenitally narrow
cannal
Spondylolishtesis: slippage of one vertebrae over another
Infection: Abscess, Potts, Pyelo
Neoplasia: spinal mets, MM
Rheum: Ankylosing spondylitis, Reiters
Zoster
5. Evaluation
If no evidence of CE, Met, Fracture, Infection or bad neuro deficit, conservative
management for 6 weeks
If radicular and no improvement, consider MRI in 6 weeks
Remember MRI false positives increase with age as there is increasing
asymptomatic disk herniation
Only get MRI if it will change your management
Red Flag Labs: LS X-ray, MRI, CBC, ESR, U/A
6. Conservative Management
Data shows quicker recovery with returning to normal activities. Dont do things
that exacerbate the pain
Heat and Ice for muscle spasm
No evidence for corsets or traction
Consdier PT if not better in 2-4 weeks
Body Mechanics
o Squat, dont bend, keep a base of support
o Keep equipment close to center of body
o Keep back in neutral position
Add Pharm as needed (see below)
7. Pharmacologic Management

NSAIDs are very effective in reducing pain: choose based on cost and SEs.
Narcotics should be used sparingly for < 7d only as needed given potential for
abuse and self-limiting course of low back pain
Muslce relaxants (cyclobenzaprine, carisoprodol) should also be used sparingly
for < 7d
o Watch for sedation
CS can be substiutied for NSAIDs but no evidence that they are better

8. Surgery
Emergent surgery necessary for some conditions.
Last resort for common low back pain
Diskectomy has good short term outcomes for disk disease, however long term
outcomes are similar with conservative therapy
In addition there is a risk of serious complications like: dural tears, diskitis, nerve
root damage and spinal instability
May have a long recovery