Definition
A.Painful conditions of the lower back may be categorized as follows:
1.Potentially serious disorders: Acute fractures, tumor, progressive neurologic deficit, nerve root compression, and cauda equina syndrome.
2.Degenerative disorders: Aging or repetitive use, degenerative disease, and osteoarthritis.
3.Nonspecific disorders: Benign and self-limiting with unclear etiology.
Incidence
A.Lower back pain is commonly seen in patients from ages 20 to 29 years, with increasing incidence until age 65 years.
B.Approximately 70% to 80% of people experience back pain at one point in their lifetime.
C.The long-term outcome of low back pain (LBP) is highly favorable.
Pathogenesis
A.Pain arises from fracture, tumor, nerve root compression, degenerative disk, osteoarthritis, and strain of the ligaments and musculature of the lumbosacral area.
Predisposing Factors
A.Trauma causing ligament tearing; stretching of vertebra, muscles, tendons, ligaments, or fascia.
B.Repetitive mechanical stress.
C.Tumor.
D.Exaggerated lumbar lordosis.
E.Abnormal, forward-tipped pelvis.
F.Uneven leg length.
G.Chronic poor posture due to inadequate conditioning of muscle strength and flexibility, improper lifting techniques causing excessive strain, and poor body mechanics.
H.Inadequate rest.
I.Emotional depression.
Common Complaints
A.Pain in the lower back area may range from discomfort to severe back pain, with or without radiation down either leg or bilaterally.
Other Signs and Symptoms
A.Ambulating with a limp.
B.Limited range of motion.
C.Posture normal to guarded.
Subjective Data
A.Ask the patient to discuss the origin of pain. How has the pain progressed or changed since the initial injury or stress?
B.Ask the patient to point to an area where pain is felt.
C.Have the patient describe the pain. Is it radiating, with sharp, shooting pain down to the lower leg and feet?
D.Ask: What makes the pain worse or better? Have the patient list current medications or therapies used for pain, noting results of treatment.
E.Investigate occurrence of systemic symptoms such as fever and weight loss.
F.Explore patient’s past medical history. Note previous trauma or overuse, tuberculosis, arthritis, cancer, and osteoporosis.
G.Inquire about symptoms such as dysuria, bowel or bladder incontinence, muscle weakness, paresthesia, and loss of sensation. Bowel or bladder dysfunction, bilateral sciatica, and saddle compression may be symptoms of severe compression of the cauda equina that necessitates an urgent workup and referral.
H.Ask the patient about precipitating factors such as athletics, heavy lifting, driving, yard work, occupation, sleep habits, or systemic disease.
I.Use a pain scale to describe the worst pain and the best pain levels.
Physical Examination
A.Check temperature, pulse, blood pressure, and respirations.
B.Inspect:
1.Observe general appearance; note discomfort and grimacing on movement and/or examination.
2.Distraction may distinguish pain behavior from actual pathology.
3.Note evidence of trauma with bruises, cuts, and fractures.
4.Note posture and gait.
C.Palpate:
1.Palpate spine and paravertebral structures, noting point tenderness and muscle spasm. Palpation elicits paravertebral tenderness and generalized tenderness over lower back to upper buttocks.
2.Examine abdomen for masses.
3.Extremities: Palpate peripheral pulses.
D.Perform neurologic examination:
1.Identify sensation and pain distribution.
2.Determine motor strength and evaluate whether muscle strength is symmetrical: Upper extremity resistance is equal bilaterally.
3.Test deep tendon reflexes (DTRs) and dorsiflexion of big toe.
E.Evaluate using the FABER test (flexion, abduction, and external rotation) or the Stork test (stand on one leg; lift the other leg and, extend backward; palpate the sacro-iliac [SI] joint on both sides while performing test). Back extension requires that you lie on your stomach, bring your legs upward, press your abdomen downward, and clasp your hands behind your shoulder blades (upper part of body should not be on the ground).
F.Check sensation of perineum to rule out cauda equina syndrome.
G.Perform traction tests: Straight leg raises, crossed leg raises, Yeoman Guying, Patrick’s test. Musculoskeletal findings include the following:
1.Straight leg raising and dorsiflexion of foot on affected side may reduce lower back discomfort.
2.Elevate each leg passively with flexion at hip and extension of knee. Positive straight leg raise is radicular pain when leg is raised 30° to 60°.
3.Crossed leg raises: Test is positive when pain occurs in leg not being raised.
4.Yeoman Guying: Unilateral hyperextension in prone position identifies lumbosacral mechanical disorder.
5.Patrick’s test: Place heel on opposite knee and apply lateral force; check for hip or sacroiliac disease.
6.Range of motion: Increased pain with extension often indicates osteoarthritis. Increased pain with flexion often indicates strain or injured disk.
H.Pelvic exam: Consider pelvic and rectal exam, if indicated. If the patient has fallen on the coccyx, a rectal exam is needed to check for stability.
Diagnostic Tests
A.Laboratory (usually unnecessary on initial exam): Complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), serum calcium, alkaline phosphatase, urinalysis, and serum immunoelectrophoresis when inflammatory conditions, neoplastic conditions, diffuse bone disease, or renal disease is suspected.
B.Radiography of spine (imaging studies not usually necessary during the first 6 weeks unless there are red flag signs/symptoms).
C.Consider the following tests (after radiography is completed):
1.MRI to rule out disk disease and tumors.
2.Bone scan to rule out cancer.
Differential Diagnoses
1.Back pain secondary to musculoskeletal pain.
2.Herniated intervertebral disease.
3.Sciatica.
4.Fracture.
5.Tumor.
6.Abdominal aneurysm.
7.Pyelonephritis.
8.Metabolic bone disease.
9.Gynecologic disease.
10.Peripheral neuropathy.
11.Depression.
12.Prostatitis.
13.Spinal stenosis.
14.Osteoarthritis.
15.Osteoporosis.
16.Ankylosing spondylitis.
Plan
A.General interventions:
1.The patient should continue physical activity as tolerated.
2.For acute muscle strain, have the patient apply local cold packs for 20 to 30 minutes several times a day for the first 24 hours. Heat packs are recommended after the initial 24 hours of injury.
3.Chronic or recurrent pain may be treated with either ice or heat applications, whichever gives relief.
B.Patient teaching:
1.Give accurate information on the prognosis for quick recovery such as continuing light physical activity, performing back-strengthening exercises, and avoiding overuse of medications.
2.Improvement occurs in most cases in a few weeks, although mild symptoms may persist.
3.Joint guidelines by the American College of Physicians and the American Pain Society recommend rehabilitative therapies for patients who do not improve after medications and self-care recommendations. Rehabilitative therapies include exercise therapy, acupuncture, massage therapy, spinal manipulation, cognitive behavioral therapy, and yoga.
4.Provide educational handouts on back exercises; see Section III: Patient Teaching Guide for Back Stretches.
5.After intense pain abates, the patient may perform low back exercises for range of motion and strengthening, and isometric tightening exercises of abdominal and gluteal muscles.
6.Teach patient knee–chest exercises. Recommend to the patient to place his or her back against the wall and contract abdominal and gluteal muscles with 5 to 10 repetitions four to six times per day.
7.Research indicates that yoga is beneficial for many types of back pain. Types of back pain benefited by yoga include musculoskeletal injury, herniated disc, spinal stenosis, spondylolisthesis, piriformis syndrome, arthritis, and sacroiliac joint derangement.
8.Encourage the patient to perform walking exercise daily.
9.Teach relaxation techniques.
10.Encourage the patient to modify work hours and job tasks.
11.Refer the patient for therapeutic massage or physical therapy as needed.
12.Obesity is often related to decreased exercise and poor physical fitness with reduced trunk muscle strength and endurance. Obese patients may experience back pain with normal activity.
C.Pharmaceutical therapy:
1.Analgesics: Acetaminophen 325 to 650 mg every 4 to 6 hours. Maximum dose is 4,000 mg a day for average adult. Inquire of any other current medications and/or over-the-counter preparations containing acetaminophen.
2.Nonsteroidal anti-inflammatory drugs (NSAIDs) Unless contraindicated due to gastrointestinal symptoms or cardiovascular disease:
a.Aspirin: 325 to 650 mg every 4 to 6 hours:
b.Ibuprofen: 400 to 800 mg every 6 to 8 hours. Maximum dose is 3.2 g a day under the care of the provider; otherwise 1.2 g a day.
c.Naproxen: 250 to 500 mg, every 12 hours (maximum dose of 1,500 mg/d).
d.Piroxicam (Feldene): 10 to 20 mg every day (progressive response to steady state over 7–10 days).
e.Meloxicam (Mobic): 7.5 to 15 mg daily (maximum dose to 15 mg/d; dialysis patients only 7.5 mg/d).
f.Celecoxib (Celebrex): 100 to 200 mg twice a day (maximum dose of 400 mg/d).
3.Muscle relaxants (examples):
a.Cyclobenzaprine HCl (Flexeril): 5 to 10 mg oral up to three times daily PRN.
b.Carisoprodol (Soma): 350 mg four times daily.
c.Methocarbamol (Robaxin): 1.5 g every day initially, then 750 to 1,000 mg every day.
d.Orphenadrine citrate (Norflex): 100 mg twice a day.
e.Metaxalone (Skelaxin): 800 mg three to four times a day.
Follow-Up
A.If pain is severe or unimproved, follow up in 24 hours.
B.If pain is moderate, reevaluate patient in 7 to 10 days.
C.See patient in 2 to 4 weeks to reevaluate condition and behavioral changes.
D.Recurrences are not uncommon but do not indicate a chronic or worsening case.
Consultation/Referral
A.Consult with a physician/specialist when considering red-flag diagnoses such as cauda equina syndrome, herniated disk, widespread neurologic involvement, carcinoma, or significant trauma.
B.Referral to a physician/specialist is recommended for patients that have symptoms indicating other conditions such as inflammatory disorders (anklosing spondylitis, rheumatoid arthritis, iritis, etc). Symptoms may include morning stiffness with gradual onset prior to age of 40 years, synovitis (inflammation of peripheral joints) skin rashes, etc.
Individual Considerations
A.Pregnancy:
1.Pregnancy is often associated with low back discomfort. This is due to the redistribution of body weight. As weight increases in the abdominal area with the growing fetus, patients tend to compensate by changing posture and tilting the spine back.
B.Adults:
1.Refer to the abovementioned material on chronic pain in the elderly. For patients older than 50 years of age presenting with no prior history of backache, consider differential diagnosis of neoplasm.
2.The most common metastasis seen is secondary to the primary site of breast cancer, prostate cancer, or multiple myeloma. Pain most prominent in a recumbent position rarely radiates into the buttock or leg.
C.Geriatrics:
1.LBP is the leading cause of disability worldwide. Geriatric patients that are at highest risk for LBP are those who had physically demanding jobs as well as those who smoke, are obese, and/or have physical/mental comorbidities. Disabilities and costs are expected to increase in the coming decade secondary to the rising older adult population within a burdened healthcare system.