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For further information, see CMDT Part 41-03: Spine Problems
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Essentials of Diagnosis
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May be categorized by pain on flexion versus pain on extension
Nerve root impingement is suspected when pain is leg-dominant rather than back-dominant
Alarming ("red flag") symptoms include unexplained weight loss, failure to improve with treatment, severe pain for more than 6 weeks, and night or rest pain
The cauda equina syndrome often presents with bowel or bladder symptoms (or both) and is an emergency
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General Considerations
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Cause is often multifactorial, although there are usually degenerative changes in the lumbar spine
Alarming symptoms for back pain caused by cancer include
Alarming symptoms for infection include
Fever
Rest pain
Recent infection (urinary tract infection, cellulitis, pneumonia)
History of immunocompromise or injection drug use
The cauda equina syndrome is suggested by
Urinary retention or incontinence
Saddle anesthesia
Decreased anal sphincter tone or fecal incontinence
Bilateral lower extremity weakness
Progressive neurologic deficits
Risk factors for back pain due to vertebral fracture include
Back pain may also be the presenting symptom in other serious medical problems including
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Globally, number one cause of disability visits
Second most common cause for primary care visits
Annual prevalence is 15–45%
Annual cost in the United States is over $87.6 billion
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In the standing position
Observe the patient's posture
Assess the active range of motion of the lumbar spine
Perform the one-leg standing extension test to assess for pain (the patient stands on one leg while extending the spine); a positive test can be caused by
In the sitting position
Test motor strength, reflexes and sensation (eTable 41–1)
Assess the major muscles in the lower extremities for weakness by eliciting a resisted isometric contraction for approximately 5 seconds
Compare the strength bilaterally to detect subtle muscle weakness
Similarly, check sensory testing to light touch in specific dermatomes for corresponding nerve root function
Finally, check the knee (femoral nerve L2–4), ankle (deep peroneal nerve L4–L5), and Babinski (sciatic nerve L5–S1) reflexes can be checked
In the supine position
Evaluate the hip for range of motion, focusing on internal rotation
Perform the straight leg raise test; it puts traction and compression forces on the lower lumbar nerve roots (Table 41–2)
In the prone position