Back Pain

Jump to: navigation, search
In Process

Author / Curator: Jacob Mirsky MD MA

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).



Learning Objectives 

  • Appreciate how common low back pain is in the community and primary care setting
  • Develop a sense of "red flags" to assess for in a patient who presents with low back pain
  • Understand the limited role of imaging and diagnostic work-up for most patients with back pain
  • Identify cost-effective and well-researched treatment strategies for low back pain

Top Teaching Points

  • Acute low back pain is a common reason for visits to primary care. Most acute low back pain is non-specific and self-limited, usually due to musculoskeletal pain and improving with self-care within 4-6 weeks.[1][2]
  • Sciatica refers to pain that radiates down the posterior or lateral leg beyond the knee [3]
  • The goal of the initial evaluation is to identify the minority of patients who have low back pain due to a specific (and worrisome) etiology or who are at risk for persistent symptoms.[4][5]
  • Routine plain or advanced imaging is not recommended in the absence of "red flag" features, which may suggest malignancy, infection, vertebral fracture, or cauda equina syndrome. Their presence may prompt urgent imaging depending on the level of clinical suspicion.
  • Patient education on the natural history of acute low back pain helps to set realistic patient expectations for diagnostic workup, treatment, and prognosis.
  • For most patients, initial self-care management for acute low back pain is recommended and includes non-pharmacologic and pharmacologic interventions.
  • For patients with non-specific low back pain and risk factors for persistent symptoms or with symptoms not improving with self-care, referral for physical therapy is warranted.

Background

  • Epidemiology: one of the most common reasons for primary care visit, with an estimated lifetime prevalence of 49-84% [6][7]
  • Risk factors: age, muscular weakness in back or abdomen, smoking, psychosocial factors including stress or anxiety, and occupational factors involving manual labor or repetitive tasks [8]
  • Physiology / Pathophysiology: while low back pain is common, the exact etiology is difficult to identify with a high degree of reliability. Most cases (>85%) are due to non-specific musculoskeletal causes such as muscle spasm, ligamentous strain, or degenerative changes (e.g. degenerative joint disease, spinal stenosis, spondylolisthesis, and spondylolysis). A minority of cases are caused by a specific disorder (e.g. compression fracture, disc herniation, malignancy, ankylosing spondylitis, cauda equina syndrome, or infection e.g. osteomyelitis or epidural abscess). [9]
  • Progression and Complications of Disease:  the vast majority of patients (75-90%) report significant improvement over the first four weeks. However, recurrence is common, with 20-50% reporting another episode over the subsequent year. Among those with acute symptoms, only 2-10% will go on to have chronic low back pain.

Differential Diagnosis

Adapted from Casazza 2012 [10]

Etiology Diagnosis Clinical Features
Intrinsic Spine Compression Fracture History of trauma (unless osteoporotic), point tenderness at spine level, pain worsens with flexion, and while pulling up from a supine to sitting position and from a sitting to standing position
Herniated nucleus pulposus Leg pain is greater than back pain and worsens when sitting; pain from L1-L3 nerve roots radiates to hip and/or anterior thigh, pain from L4-S1 nerve roots radiates to below the knee; positive Straight Leg Raise test
Lumbar strain/sprain Diffuse back pain with or without buttock pain, pain worsens with movement and improves with rest, variable tenderness to palpation over affected area
Spinal stenosis Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)
Spondylolisthesis Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral or bilateral
Spondylolysis Can cause back pain in adolescents, although it is unclear whether it causes back pain in adults; pain worsens with spine extension and activity
Spondylosis (degenerative disk or facet joint arthropathy) Similar to lumbar strain; disk pain often worsens with flexion activity or sitting, facet pain often worsens with extension activity, standing, or walking
Systemic Connective tissue disease Multiple joint arthralgias, fever, weight loss, fatigue, spinous process tenderness, other joint tenderness
Inflammatory spondyloarthropathy Intermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis to lumbar flexion
Malignancy Pain worsens in prone position, spinous process tenderness, recent weight loss, fatigue
Vertebral diskitis, paraspinal abscess, and osteomyelitis Constant pain, spinous process tenderness, often no fever, normal complete blood count, elevated erythrocyte sedimentation rate and/ or C-reactive protein level
Referred Abdominal aortic aneurysm Abdominal discomfort, pulsatile abdominal mass
Gastrointestinal conditions: pancreatitis, peptic ulcer disease, cholecystitis Abdominal discomfort, nausea\vomiting, symptoms often associated with eating
Herpes zoster Unilateral dermatomal pain, often allodynia, vesicular rash
Pelvic conditions: endometriosis, pelvic inflammatory disease, prostatitis Discomfort in lower abdomen, pelvis, or hip
Retroperitoneal conditions: renal colic, pyelonephritis Costovertebral angle pain, abnormal urinalysis results, possible fever

Diagnosis

History

[11][12][13][14]

  • First onset of symptoms
  • History of osteoporosis, cancer, recent infection, HIV, steroids, or immunosuppression
  • Prior sciatica, prior exacerbations, history of anxiety/depression, previous treatment modalities (medications, patches, injections, surgeries, integrative modalities)
  • Social history: smoking, IVDU, substance use, psychosocial distress, occupational factors

Signs and Symptoms

[15][16][17]

  • First rule out red flag symptoms (fevers, trauma, motor/sensory deficits, urinary retention, saddle anesthesia, history of or active treatment for malignancy, weight loss, difficulty sleeping, IVDU, chronic steroids or immunosuppression, osteoporosis)
  • Then assess for specific etiologies of low back pain (radiular pain or worsened pain with sitting suggestive of sciatica, back/leg pain with walking or standing that is relieved by sitting or spinal flexion suggestive of spinal stenosis, history of IBD or psoriasis or morning stiffness suggestive of seronegative spondyloarthritis)

Physical Exam Findings

[18]

Inspection

  • Assess for signs of trauma, scoliosis, kyphosis, swelling, or redness
  • Range of motion of spine and hip

Palpation

  • Assess for warmth
  • Palpation for midline vertebrae, ilolumbar ligament, and sacroiliac joint for deformity or tenderness

Neurologic Exam

  • Lower extremity strength (and corresponding nerve root)
    1. Dorsiflexion of the foot, heel walking (L4-5)
    2. Dorsiflexion of great toe (L5)
    3. Plantarflexion of the foot, toe walking (S1)
  • Lower extremity reflexes (and corresponding nerve root)
    1. Achilles tendon (S1)
    2. Patellar (L4)
  • Rectal exam for sphincter tone if cauda equina suspected

Maneuvers

  • FABER Test (Patrick's Test) if pain into buttock or leg to assess for hip pathology - with patient supine, thigh and knee are flexed, external malleolus placed over patella of opposite leg knee is depressed; pain suggests arthritis of hip or sacroiliac pathology
  • Straight leg raise test: raising affected leg with ankle in dorsiflexion and knee extended while patient supine; reproduction of leg pain when angle of the leg between 30 and 60 degrees; 70% sensitive for disc herniation but non-specific
  • Crossed straight leg raise: with patient supine, raising unaffected leg with knee extended; reproduction of pain in the affected leg; 90% specific for disc herniation but insensitive

Recommended Work-up

[19][20][21][22][23][24][25][26][27]<ref?Brinjikji et al.: Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811-6. </ref>

  • Most patients with acute low back pain do not require laboratory tests or imaging studies during initial evaluation and treatment.
  • Inflammatory markers (ESR/CRP) may be helpful if there is suspicion for infection or inflammatory arthritis.
  • Guidelines by ACP and APS recommend against imaging in the initial evaluation of nonspecific low back pain, but do recommend imaging if back pain is severe or there are progressive neurologic deficits or serious underlying condition suspected. MRI is preferred to CT to assess for severe or progressive neurologic deficits and suspected serious conditions such as cauda equina syndrome, cancer, or infection.

Management

Overview: for most patients with acute low back pain, symptoms improve with self-care over 4-6 weeks. A generally approach to patient pain that you can employ in the clinical setting is as follows:

  1. Conservative (i.e. non-pharmacologic) management with usual activity and avoidance of strenuous activities (e.g. lifting)
  2. Non-pharmacologic pain management with superficial heat, stretching, and physical therapy with consideration of acupuncture or chiropractic manipulations
  3. Stepwise pharmacologic pain management with first NSAIDs (if patient does not have chronic kidney disease or peptic ulcer disease) rather than acetaminophen, and then progression to muscle relaxants (e.g. cyclobenzaprine)
  4. Consideration of more aggressive measures such as opioids or anti-depressant/anti-epileptic medications

Non-pharmacological treatment

  • Continue usual activities as tolerated; avoid prolonged bed rest. [28][29][30]
  • Superficial heat application (i.e., heat wrap) provides moderate improvement in pain and function.[31]
  • Massage may provide a small-to-moderate improvement in pain and function.[32]
  • Acupuncture and chiropractic manipulation may provide small benefit.[33][34]

Pharmacological treatments

  • Acetaminophen (Tylenol) is not effective for acute low back pain. [35]
  • NSAIDs such as ibuprofen and naproxen are associated with small improvement in pain and function. They are considered first-line pharmacologic treatment for acute low back pain. There is no evidence that prescription NSAIDs are more effective than over-the-counter NSAIDs. [36][37]
  • Skeletal muscle relaxants such as cyclobenzaprine are associated with small improvement in pain and are considered second-line pharmacologic treatment for acute low back pain.[38]
  • Benzodiazepines may provide muscle relaxant effects but with increased sedation and risk of misuse. They are not recommended due to limited evidence. [39][40]
  • Systemic corticosteroids are not effective for acute low back pain with or without radiculopathy.[41]
  • TCAs, SNRIs, and anti-epileptics are sometimes used in the management of chronic low back pain; however, these are not well-studied in acute low back pain.
  • Opioids and tramadol are not recommended for acute low back pain and should be reserved for severe, debilitating pain that is not controlled with other interventions. If opioids or benzodiazepines are prescribed, specific instructions for use (not "prn") and a limited supply with no refills are recommended due to risk for misuse.[42][43]
  • Patients prescribed muscle relaxants, benzodiazepines, or opioids should be advised not to drive or use alcohol and should be considered unable to work if using medications during the day. These classes of medications should be used with caution in elderly patients.

Other Teaching Pearls

  • The prognosis for acute low back pain is excellent; only one-third of patients seek medical care at all[44]
  • Chronic back pain is diagnosed in 20 percent of patients within two years of their initial visit [45]

Trial Summaries

  • Brinjikji et al. 2015 [46] - imaging findings of spine degeneration are present in high proportions of asymtpomatic individuals and many of these features are unassociated with pain
  • Shmagel et al. 2018 [47] - despite the ongoing national opioid epidemic, opioids are the most common prescription pain medication for patients with chronic low back pain, and this was found disproportionately among individuals with less than a college education

Ongoing controversies / New updates

  • Low back pain exercises run the risk of exacerbating low back pain, but it appears that exercise in general does not appear to increase the risk of exacerbation[48][49]
  • A meta-analysis of spinal manipulation in acute low back pain management showed modest improvements in pain and function with transient minor harms, however studies are heterogeneous and so generalization is challenging [50]

Teaching Resources

Videos:

Podcast episodes:

Core review articles / Guidelines:

References

Back Pain

  1. Deyo & Tsui-Wu: Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 1987;12:264-8.
  2. Cassidy et al.: The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine 1998;23:1860-6; discussion 1867.
  3. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  4. Deyo et al.: What can the history and physical examination tell us about low back pain?. JAMA 1992;268:760-5.
  5. Jarvik & Deyo: Diagnostic evaluation of low back pain with emphasis on imaging. Ann. Intern. Med. 2002;137:586-97.
  6. Koes et al.: Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
  7. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  8. Koes et al.: Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
  9. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  10. Casazza &: Diagnosis and treatment of acute low back pain. Am Fam Physician 2012;85:343-50.
  11. Koes et al.: Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
  12. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  13. Chou et al.: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann. Intern. Med. 2007;147:478-91.
  14. Chou &: In the clinic. Low back pain. Ann. Intern. Med. 2014;160:ITC6-1.
  15. Koes et al.: Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
  16. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  17. Chou &: In the clinic. Low back pain. Ann. Intern. Med. 2014;160:ITC6-1.
  18. Casazza &: Diagnosis and treatment of acute low back pain. Am Fam Physician 2012;85:343-50.
  19. Koes et al.: Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
  20. Kinkade &: Evaluation and treatment of acute low back pain. Am Fam Physician 2007;75:1181-8.
  21. Chou et al.: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann. Intern. Med. 2007;147:478-91.
  22. Deyo & Diehl: Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med 1988;3:230-8.
  23. Chelsom & Solberg: Vertebral osteomyelitis at a Norwegian university hospital 1987-97: clinical features, laboratory findings and outcome. Scand. J. Infect. Dis. 1998;30:147-51.
  24. Beronius et al.: Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95. Scand. J. Infect. Dis. 2001;33:527-32.
  25. Kapeller et al.: Pyogenic infectious spondylitis: clinical, laboratory and MRI features. Eur. Neurol. 1997;38:94-8.
  26. Chou et al.: Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann. Intern. Med. 2011;154:181-9.
  27. Miller et al.: Magnetic resonance imaging of the spine. Mayo Clin. Proc. 1989;64:986-1004.
  28. Dahm et al.: Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010;:CD007612.
  29. Malmivaara et al.: The treatment of acute low back pain--bed rest, exercises, or ordinary activity?. N. Engl. J. Med. 1995;332:351-5.
  30. Hill et al.: Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71.
  31. French et al.: Superficial heat or cold for low back pain. Cochrane Database Syst Rev 2006;:CD004750.
  32. Furlan et al.: Massage for low-back pain. Cochrane Database Syst Rev 2015;:CD001929.
  33. Liu et al.: Acupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med 2015;2015:328196.
  34. Paige et al.: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA 2017;317:1451-1460.
  35. Williams et al.: Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014;384:1586-96.
  36. Roelofs et al.: Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008;:CD000396.
  37. Machado et al.: Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann. Rheum. Dis. 2017;76:1269-1278.
  38. van Tulder et al.: Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003;:CD004252.
  39. van Tulder et al.: Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003;:CD004252.
  40. Friedman et al.: Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain. Ann Emerg Med 2017;70:169-176.e1.
  41. Chou et al.: Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann. Intern. Med. 2017;166:493-505.
  42. Dowell et al.: CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65:1-49.
  43. Abdel Shaheed et al.: Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med 2016;176:958-68.
  44. Carey et al.: Acute severe low back pain. A population-based study of prevalence and care-seeking. Spine 1996;21:339-44.
  45. Mehling et al.: The prognosis of acute low back pain in primary care in the United States: a 2-year prospective cohort study. Spine 2012;37:678-84.
  46. Brinjikji et al.: Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811-6.
  47. Shmagel et al.: Prescription Medication Use Among Community-Based U.S. Adults With Chronic Low Back Pain: A Cross-Sectional Population Based Study. J Pain 2018;:.
  48. Rainville et al.: The influence of intense exercise-based physical therapy program on back pain anticipated before and induced by physical activities. Spine J 2004;4:176-83.
  49. Choi et al.: Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev 2010;:CD006555.
  50. Paige et al.: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA 2017;317:1451-1460.