Definition
A.Pain in the lower back region, which may, or may not, have a radicular component.
B.Low back pain (LBP) is categorized into three groups, based on duration of symptoms.
1.Acute LBP: Pain that is 6 weeks or less in duration.
2.Sub-acute LBP: Pain that continues between 6 and 12 weeks.
3.Chronic LBP: Pain that is more than 3 months in duration.
C.Types of LBP.
1.Benign back pain is a dull, aching pain that generally worsens with movement but improves with rest and lying.
2.Tumor- or infection-related back pain typically presents with constant and dull pain. This pain is unrelieved by rest and is worse at night, therefore often awakening the patient.
3.Disc herniation is worsened by coughing, valsalva maneuver, and sitting and is relieved by lying in the supine position.
4.Spinal stenosis is associated with bilateral (and occasionally unilateral) sciatic pain that is worsened by activities such as walking, prolonged standing, and back extension. Pain is relieved by rest and forward flexion.
Incidence
A.The lifetime incidence of LBP is 70% and has an incidence of 5% per year.
B.The peak incidence of LBP is in the age range of 40s to 50s.
C.LBP is the second most common reason for physician visits in the United States.
D.For approximately 90% of the patients, the most common cause of LBP is related to disc degeneration.
Pathogenesis
A.LBP presents suddenly from an accident, fall, whiplash injury, or heavy lifting.
B.LBP develops gradually as a result of age-related changes to the spine.
C.Bony overgrowth (osteophytes) or disc herniation may directly impinge on spinal nerve roots or the spinal cord itself and can lead to instability and misalignment of the spine, which produces pain and neurological deficits.
D.Radiculopathy is caused by compression, inflammation, or injury to a spinal nerve root.
E.Sciatica is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg.
F.Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column.
G.Spinal stenosis is the narrowing of the spinal column, which then leads to pressure on the spinal cord and nerves.
1.The spinal cord pressure can cause pain or numbness with walking and may, over time, lead to leg weakness and sensory loss.
2.This is also known as neurogenic claudication.
Predisposing Factors
A.The first attack typically occurs between ages 30 and 40.
B.African American female.
C.Diet high in calories and fat.
D.Inactive lifestyle.
E.Obesity.
F.Cigarette smoking.
G.Occupation: Job that requires heavy lifting, pushing, pulling, or twisting.
Subjective Data
A.Common complaints/symptoms.
1.LBP with radiation to buttocks, legs, or feet.
2.Paraspinal muscle spasms.
3.Muscle stiffness.
4.Paresthesias.
5.Gait disturbances.
6.Numbness.
B.Common/typical scenario.
1.Neurogenic claudication (low back, buttock, or leg pain, which may be relieved by sitting or with rest, induced by walking or standing).
2.Fecal or urinary incontinence.
3.Large post void residual greater than 100 mL and overflow incontinence.
4.Perianal or perineal sensory loss.
5.Dermatomal sensory loss.
6.Focal leg weakness, paralysis, and hyporeflexia in the legs.
7.Elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and human leukocyte antigen (HLA), if infection is present.
8.Fever.
C.Family and social history.
1.Family history is typically noncontributory.
2.Social history.
a.Smoking, which is associated with LBP.
b.Dietary and eating habits.
c.Obesity is a major cause of LBP.
d.Elicit drug use.
D.Review of systems.
1.Elicit onset, frequency, duration, and location of symptoms.
2.Inquire if pain is worse during activity, at rest, or at night.
3.Inquire about exacerbating factors.
4.Inquire if pain radiates to lower extremities.
5.Inquire about associated symptoms, such as numbness, tingling, weakness, and sensory deficits.
6.Determine if there is any recent loss or change in bowel or bladder function.
7.Check if there is symptom improvement after taking pain medications.
8.Determine whether patient has a history of trauma and chronic infection.
9.Check for signs of systemic disease, which include history of cancer, age greater than 50 years, unexplained weight loss, duration of pain greater than 1 month, night-time pain, and unresponsiveness to previous therapies.
Physical Examination
A.Check vital signs: Blood pressure, heart rate, respirations, and temperature.
B.Inspect.
1.Examine the back for any warmth, erythema, swelling, purulent drainage, or abscess.
2.Inspect the curvature of the spine.
3.Observe for signs of previous surgery.
C.Check for tenderness or pain using palpation along the spine.
D.Check for radicular pain associated with straight-leg test.
1.Straight-leg raise test is positive if test causes radicular pain of the affected leg radiating below the knee.
E.Complete neurological examination including:
1.Motor strength.
2.Sensation.
3.Deep tendon reflexes.
F.Check back range of motion (ROM): Flexion, extension, side bending, and rotation.
G.Check hip ROM: Possible referred pain from hip pathology.
H.Assess gait.
I.Perform digital rectal examination to assess rectal sphincter tone or anal sphincter laxity.
Diagnostic Tests
A.Spine x-rays or films.
1.Anteroposterior and lateral views.
2.Demonstrates fractures, disc space narrowing, osteophyte formation, tumor, or instability.
B.MRI scan.
1.Provides axial and sagittal views, which demonstrate normal and pathologic discs, ligaments, nerve roots, epidural fat, and shape and size of the spinal canal.
2.Gold standard study in cases of suspected spinal infection, neoplasm, and epidural compression syndromes.
C.CT scan.
1.Useful in evaluating vertebral fractures, facet joints, and posterior elements of the spine.
2.When MRI scan is unavailable, CT myelography is the best substitute for conditions, such as epidural abscess or cord compression.
D.Nuclear medicine bone scan.
1.Can also be used if infection and tumor are suspected.
E.Laboratory tests: ESR, CRP, complete blood count (CBC), blood cultures, and urinalysis.
Differential Diagnosis
A.Degenerative disc disease.
B.Spinal stenosis.
C.Spondylosis and spondylolisthesis.
D.Discitis.
E.Vertebral osteomyelitis.
F.Spinal cord or cauda equina compression.
G.Herniated intervertebral disc.
H.Spinal epidural abscess.
I.Ankylosing spondylitis.
J.Spine-related bone tumors.
K.Metastatic cancer.
L.Scoliosis and hyperkyphosis.
M.Vertebral compression fracture.
N.Myofascial pain syndrome.
O.Fibromyalgia pain syndrome.
Evaluation and Management Plan
A.General plan.
1.General intervention.
a.Bed rest for a few days. Limit bending, lifting, and twisting.
b.Physical therapy and aerobic exercise.
c.Local application of heat and ice.
d.Brace is indicated for adolescents with spine curvature between 20°C and 40°C.
2.Adjunct therapy.
a.Transcutaneous electrical nerve stimulation (TENS).
b.Biofeedback.
c.Acupuncture.
3.Red flags: Indications for imaging.
a.Concern for malignancy: Age 50 or older, previous history of cancer, unexplained weight loss, pain unrelieved by bed rest, pain lasting more than a month, or LBP failure to improve in 1 month.
b.Concern for infection: Elevated ESR greater than 20, intravenous drug abuse, urinary tract infection, skin infection, or fever.
c.Concern for compression fracture: Corticosteroid use and/or age 50 or older.
d.Concern for neurological problem: Sciatica.
e.New fecal or urinary incontinence.
4.Surgical intervention.
a.Indications for surgery when all three criteria are met.
i.Evidence of disc herniation as demonstrated by an imaging study.
ii.Worsening clinical picture with neurological deficit.
iii.Failed improvement after 4 to 6 weeks of conservative treatment.
iv.NOTE: Cauda equina and spinal cord compression syndromes need urgent surgical decompression in 24 to 48 hours of symptom onset.
v.Imaging demonstrates compressive abscess or epidural collection.
b.Types of spine surgery.
i.Vertebroplasty and kyphoplasty are minimally invasive treatments to repair compression