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Back Pain, Low
Millicent King Channell, DO, MA, FAAO
image BASICS
DESCRIPTION
  • Low back pain (LBP) is extremely common and includes a wide range of symptoms involving the lumbosacral spine and pelvic girdle.
  • LBP can be characterized by duration or associated symptoms.
  • Duration (1)[A]
    • Acute (<6 weeks)
    • Subacute (>6 weeks but <3 months)
    • Chronic (>3 months)
  • Associated symptoms (1)[A]
    • Localized/nonspecific “mechanical” LBP
    • Back pain with lower extremity symptoms
    • Systemic and visceral symptoms
  • A specific cause is not found for most patients with LBP. Most cases resolve in 4 to 6 weeks.
  • Rule out “red” flag symptoms indicating the need for immediate intervention.
  • System(s) affected: musculoskeletal, neurologic
  • Synonym(s): lumbago, lumbar sprain/strain, low back syndrome
EPIDEMIOLOGY
Incidence
  • 1-year incidence: 6-15% (1)[A]
  • LBP is one of the most common primary care complaints (1)[A].
Prevalence
  • Lifetime prevalence: 84% (1)[A]
  • Global point prevalence: 9% (1)[A]
  • Predominant sex: male = female
  • Age: The highest incidence is in the 3rd decade (20 to 29 years); overall prevalence increases with age until age 65 years and then declines (1)[A].
ETIOLOGY AND PATHOPHYSIOLOGY
A clear etiology is not found in most patients. Age-related degenerative changes of the lumbosacral spine, and atrophy of supporting musculature may contribute (2)[A].
RISK FACTORS
  • Age (1)[A.]
  • Activity (lifting, sudden twisting, bending) (1)[A]
  • Obesity (1)[A]
  • Sedentary lifestyle (1)[A]
  • Physically strenuous work (1)[A]
  • Psychosocial factors—anxiety, depression, stress (1)[A]
  • Smoking (1)[A]
GENERAL PREVENTION
  • Maintain normal weight (1)[A].
  • Adequate physical fitness and activity (1)[A].
  • Stress reduction (1)[A]
  • Proper lifting technique and good posture
  • Smoking cessation
  • There is insufficient evidence to recommend for or against routine preventive measures in adults.
image DIAGNOSIS
PHYSICAL EXAM
  • Observe gait, position on examination table, and facial expressions.
  • Test lumbar spine range of motion.
  • Evaluate for point tenderness or muscle spasm.
    • Neurologic examination. Inspection: signs of muscle atrophy
    • Completely evaluate reflexes, strength, pulses, sensation
    • Straight leg test
    • FABER test (flexion, abduction, and external rotation)
    • Stork test: Stand on one leg with opposite hip held in flexion. Extend back. Pain in lumbosacral area is a positive test.
DIFFERENTIAL DIAGNOSIS
  • Localized/nonspecific “mechanical” LBP (87%) (1)[A]
  • Lumbar strain/sprain (70%)
    • Disc/facet degeneration (10%)
    • Osteoporotic compression fracture (4%)
    • Spondylolisthesis (2%)
    • Severe scoliosis, kyphosis
    • Asymmetric transitional vertebrae (<1%)
    • Traumatic fracture (<1%)
  • Back pain with lower extremity symptoms (7%) (1)[A]
    • Disc herniation (4%)
    • Spinal stenosis (3%)
  • Systemic and visceral symptoms (1)[A]
    • Neoplasia (0.7%)
      • Multiple myeloma; metastatic carcinoma
      • Lymphoma/leukemia
      • Spinal cord tumors, retroperitoneal tumors
    • Infection (0.01%)
      • Osteomyelitis
      • Septic discitis
      • Paraspinous abscess; epidural abscess
      • Shingles
    • Inflammatory disease (0.03%)
      • Ankylosing spondylitis, psoriatic spondylitis
      • Reactive arthritis
      • Inflammatory bowel disease
    • Visceral disease (0.05%)
      • Prostatitis
      • Endometriosis
      • Chronic pelvic inflammatory disease
      • Nephrolithiasis, pyelonephritis
      • Perinephric abscess
      • Aortic aneurysm
      • Pancreatitis; cholecystitis
      • Penetrating ulcer
    • Other
      • Osteochondrosis
      • Paget disease
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Imaging studies are unnecessary during the first 6 weeks if no red flag signs or symptoms.
  • X-ray of the lumbar spine (1,3,4)[A]
    • Not recommended for initial presentation or without red flags including trauma. Defer films for 6 weeks unless there is a high risk of disease.
    • Useful for bony etiology (e.g., fracture)
  • MRI of the lumbar spine (1,3,4)[A] for patients presenting with neurologic deficits, failure to improve with 6 weeks of conservative treatment, or if there is a strong suspicion of cancer or cauda equina syndrome.
    • Useful for suspected herniated disc, nerve root compression, or metastatic disease
  • CT scan of the lumbar spine (1,3,4)[A]
    • Appropriate alternative to MRI for patient with pacemaker, metallic hardware, or other contraindication to MRI
  • Labs are unnecessary with initial presentation if no related red flags, signs, or symptoms present (1,3,4)[A]
  • If infection or bone marrow neoplasm is suspected, consider (1,3,4)[A]
    • Complete blood count (CBC) with differential
    • Erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP) level
P.105

Diagnostic Procedures/Other
Neurosurgical consult for acute neurologic deficits or suspected cauda equina syndrome (1,4)[A]
image TREATMENT
The primary goal is to provide supportive care and allow return to functional activity. Patients should be aware of alarm symptoms that prompt a return visit.
First Line
  • Patient education (4)[A]
    • Reassure patients that pain is usually self-limited; treatment should relieve pain and improve function.
    • Encouraging activity as tolerated leads to quicker recovery.
  • Medications (1,3,5)[A]
    • Acetaminophen 325 to 650 mg PO q4-6h PRN pain (max 4 g/day)
    • NSAIDs
      • Ibuprofen 400 to 600 mg PO 3 to 4 times daily (max 3,200 mg/day)
      • Naproxen 250 to 500 mg PO q12h (max 1,500 mg/day)
    • Manual medicine (4)[A], osteopathic manipulative treatments (OMT) (4)[A],(6)[B]: myofascial, counter-strain, bilateral ligamentous techniques, as well as muscle energy, if tolerated
  • Obstetric considerations (6,7)[B]
    • Use medications cautiously in pregnancy—benefit must clearly outweigh risk.
  • OMT and chiropractic care may be used in a multi-disciplinary approach in the general population as well as the obstetric patient.
Second Line
  • Second-line therapy for moderate to severe pain (1,3,5)[A]
    • Cyclobenzaprine 5 to 10 mg PO up to TID PRN (max 30 mg/day)
    • Tizanidine 2 mg PO up to TID PRN
    • Hydrocodone 2.5 to 10 mg PO q4-6h PRN pain; use of hydrocodone or other opioids for LBP is based on clinical judgment.
  • Other treatments (1,3)[A]
    • Antidepressants (1,3,5)[A]
      • Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) have been shown in randomized trials to provide a small pain reduction in patients. No clear evidence that SSRIs are more effective than placebo in cases of chronic LBP.
  • Injections (8)[A]
    • Facet: lumbar radiofrequency neurotomy, therapeutic facet joint nerve blocks in the lumbar spine, and lumbar intra-articular injections have all shown benefit
    • Epidural: provides short-term relief of persistent pain associated with documented radicular symptoms caused by herniated disc (1,3,4,8)[A]
Geriatric Considerations
  • Older persons taking nonselective NSAIDs should use a proton pump inhibitor or misoprostol for gastrointestinal protection.
  • Patients taking a COX-2 selective inhibitor with aspirin should use a proton pump inhibitor or misoprostol for gastrointestinal protection.
  • Age-related decline in cytochrome P-450 function and polypharmacy (common in elderly patients) increases risk for adverse medication reactions.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture is superior to no treatment, but evidence is mixed regarding the effectiveness of acupuncture over other treatment modalities (1,3,4)[A].
  • Yoga can help with chronic LBP (1,3,4)[A].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Regular exercise (3,9)[A]
  • Patient education regarding chronicity, recurrence, and red flags (3,9)[A]
Patient Monitoring
  • Reassurance is key. Follow up within 2 to 4 weeks of initial presentation to monitor progress. Most patients spontaneously improve.
    • Assess severity and quality of pain as well as range of motion and other historical features (red flags).
  • Reevaluate for possible underlying organic causes for pain if patients fail to improve.
REFERENCES
1. Golob AL, Wipf JE. Low back pain. Med Clin North Am. 2014;98(3):405-428.
2. Duffy RL. Low back pain: an approach to diagnosis and management. Prim Care. 2010;37(4):729-741.
3. Chaparro LE, Furlan AD, Deshpande A, et al. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine (Phila Pa 1976). 2014;39(7):556-563.
4. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.
5. Lee TJ. Pharmacologic treatment for low back pain: one component of pain care. Phys Med Rehabil Clin N Am. 2010;21(4):793-800.
6. Hensel KL, Buchanan S, Brown SK, et al. Pregnancy research on osteopathic manipulation optimizing treatment effects: the PROMOTE study. Am J Obstet Gynecol. 2015;212(1):108.e1-108.e9.
7. George JW, Skaggs CD, Thompson PA, et al. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. 2013;208(4):295.e1-295.e7.
8. Manchikanti L, Kaye AD, Boswell MV, et al. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician. 2015;18(4):E535-E582.
9. Savigny P, Watson P, Underwood M; Guideline Development Group. Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ. 2009;338:b1805.
Additional Reading
  • de Leon-Casasola OA. Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am J Med. 2013;126(3)(Suppl 1):S3-S11.
  • Engers A, Jellema P, Wensing M, et al. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057.
  • Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-846.
  • Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;(7):CD002014.
  • Hutchinson AJ, Ball S, Andrews JC, et al. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012;7:36.
  • Kuijpers T, van Middelkoop M, Rubinstein SM, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20(1):40-50.
  • Urquhart DM, Hoving JL, Assendelft WW, et al. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev. 2010;(1):CD001703.
  • Walker BF, French SD, Grant W, et al. A Cochrane review of combined chiropractic interventions for low-back pain. Spine (Phila Pa 1976). 2011;36(3):230-242.
See Also
  • Lumbar (Intervertebral) Disc Disorders
  • Algorithm: Low Back Pain, Acute
Codes
ICD10
  • M54.5 Low back pain
  • G89.29 Other chronic pain
Clinical Pearls
  • LBP is one of the most common complaints in primary care. Most patients do not have an identifiable cause of pain, and most cases resolve spontaneously within 4 to 12 weeks of onset.
  • Assess for red flag symptoms in every patient.
  • Labs and imaging studies are unnecessary for most cases of back pain if no red flag symptoms are present.
  • In the absence of red flags, physical activity as tolerated speeds recovery.