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The cost of low back pain (LBP) in the United States is ~$100 billion annually. Back symptoms are the most common cause of disability in those <45 years; LBP is the second most common cause of visiting a physician in the United States; ~1% of the United States population is disabled because of back pain.


  • Local pain—caused by stretching of pain-sensitive structures that compress or irritate nerve endings; pain (i.e., tears, stretching) located near the affected part of the back.

  • Pain referred to the back—abdominal or pelvic origin; back pain unaffected by routine movements.

  • Pain of spine origin—restricted to the back or referred to lower limbs or buttock. Diseases of upper lumbar spine refer pain to upper lumbar region, groin, or anterior thighs. Diseases of lower lumbar spine refer pain to buttocks, posterior thighs, or rarely the calves or feet.

  • Radicular back pain—radiates from spine to leg in specific nerve root territory. Coughing, sneezing, lifting heavy objects, or straining may elicit pain.

  • Pain associated with muscle spasm—diverse causes; accompanied by taut paraspinal muscles and abnormal posture.


Include abdomen, pelvis, and rectum to search for visceral sources of pain. Inspection may reveal scoliosis or muscle spasm. Palpation may elicit pain over a diseased spine segment. Pain from hip may be confused with spine pain; manual internal/external rotation of leg at hip (knee and hip in flexion) reproduces the hip pain.

Straight leg raising (SLR) sign—elicited by passive flexion of leg at the hip with pt in supine position; maneuver stretches L5/S1 nerve roots and sciatic nerve passing posterior to the hip; SLR sign is positive if maneuver reproduces the pain. Crossed SLR sign—positive when SLR on one leg reproduces symptoms in opposite leg or buttocks; nerve/nerve root lesion is on the painful side. Reverse SLR sign—passive extension of leg backwards with pt standing; maneuver stretches L2–L4 nerve roots, lumbosacral plexus, and femoral nerve passing anterior to the hip.

Neurologic exam—search for focal atrophy, weakness, reflex loss, diminished sensation in a dermatomal distribution. Findings with radiculopathy are summarized in Table 54-1.


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