Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 41-03: Spine Problems + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ 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 +++ General Considerations ++ Cause is often multifactorial, although there are usually degenerative changes in the lumbar spine Alarming symptoms for back pain caused by cancer include Unexplained weight loss Failure to improve with treatment Pain for more than 6 weeks Pain at night or rest Age > 50 years History of cancer 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 Use of corticosteroids Age > 70 years History of osteoporosis Severe trauma Presence of a contusion or abrasion Back pain may also be the presenting symptom in other serious medical problems including Abdominal aortic aneurysm Peptic ulcer disease Kidney stones Pancreatitis +++ Demographics ++ 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 + Clinical Findings Download Section PDF Listen +++ +++ Physical Examination ++ In the standing position Observe the patient's posture Commonly encountered spinal asymmetries include scoliosis, thoracic kyphosis, and lumbar hyperlordosis 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 Pars interarticularis fractures (spondylolysis or spondylolisthesis) or Facet joint arthritis 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 Carefully palpate each level of the spine and sacroiliac joints for tenderness Perform a rectal examination if the cauda equina syndrome is suspected ++Table Graphic Jump LocationeTable 41–1.Spine: back examination.View Table||Download (.pdf)eTable 41–1. Spine: back examination. Maneuver Description Inspection Check the patient's posture in the standing position. Assess for hyperlordosis, kyphosis, and scoliosis. Palpation Include important landmarks: spinous process, facet joints, paravertebral muscles, sacroiliac joints, and sacrum. Range of motion testing Check range of motion actively (patient performs) and passively (clinician performs) especially with flexion and extension of the spine. Rotation and lateral bending are also helpful to assess symmetric motion or any restrictions. Neurologic examination Check motor strength, reflexes and dermatomal sensation in the lower extremities. Straight leg raise test The patient lies supine and the clinician elevates the patient's leg. A positive test for sciatica pain is classically described as "electric shock"-like pain radiating down the posterior aspect of the leg from the low back. This can occur in the setting of a disk herniation or degenerative conditions causing neural foraminal stenosis. Cross-over pain, where sciatica symptoms occur down the opposite leg during a straight leg raise, usually indicates a large disk herniation. Indirect straight leg raise test The patient sits on the side of the exam table with the knees bent. The clinician extends the knee fully. A positive test for sciatica pain is classically described as "electric shock"-like pain radiating down the posterior aspect of the leg from the low back. Cross-over pain, where sciatica symptoms occur down the opposite leg during a straight leg raise, usually indicates a large disk herniation. ++Table Graphic Jump LocationTable 41–2.Neurologic testing of lumbosacral nerve disorders.View Table||Download (.pdf) Table 41–2. Neurologic testing of lumbosacral nerve disorders. Nerve Root Motor Reflex Sensory Area L1 Hip flexion None Groin L2 Hip flexion None Thigh L3 Extension of knee Knee jerk Knee L4 Dorsiflexion of ankle Knee jerk Medial calf L5 Dorsiflexion of first toe Babinski reflex First dorsal web space between first and second toes S1 Plantar flexion of foot, knee flexors, or hamstrings Ankle jerk Lateral foot S2 Knee flexors or hamstrings Knee flexor Back of the thigh S2–S4 External anal sphincter Anal reflex, rectal tone Perianal area +++ Differential Diagnosis ++ Muscular strain Herniated disk Lumbar spinal stenosis Compression fracture Degenerative joint disease Infectious diseases (eg, osteomyelitis, epidural abscess, subacute bacterial endocarditis) Neoplastic disease (vertebral metastases) Seronegative spondyloarthropathies, eg, ankylosing spondylitis Leaking abdominal aortic aneurysm Renal colic + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ Diagnostic imaging, including radiographs, is not typically recommended in the first 6 weeks unless alarming "red flag" symptoms suggesting infection, malignancy, or cauda equina syndrome are present If done, radiographs of the lumbar spine should include anteroposterior and lateral views Oblique views can be useful if the neural foramina or lesions need to be visualized MRI of the lumbosacral spine is the method of choice to evaluate symptoms not responding to conservative treatment or "red flags" for serious conditions +++ Diagnostic Procedures ++ Electromyography or nerve conduction studies May be useful in assessing patients with possible nerve root symptoms lasting longer than 6 weeks Not usually necessary if the diagnosis of radiculopathy is clear + Treatment Download Section PDF Listen +++ +++ Medications ++ Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in early treatment Muscle relaxants Limited evidence that they provide short-term relief Best used if there is true muscle spasm that is painful Should be used with care due to potential for addiction Opioids may be necessary to alleviate pain immediately Gabapentin, duloxetine, and nortriptyline may be helpful in treating more chronic neuropathic pain +++ Surgery ++ Indications Cauda equina syndrome Ongoing morbidity with no response to > 6 months of conservative treatment Cancer Infection Severe spinal deformity Surgery can improve pain but is unlikely to cure it +++ Therapeutic Procedures ++ Nonpharmacologic treatments are key in the management of low back pain Education alone improves patient satisfaction with recovery and recurrence Physical therapy exercise programs can be tailored to the patient's symptoms and pathology Improvements in posture, core stability strengthening, physical conditioning, and modifications of activities to decrease physical strain are keys for ongoing management Spinal manipulation, massage, and acupuncture do have limited evidence for relieving chronic low back pain Heat and cold treatments have no long-term benefits but may provide short-term symptom relief The efficacy of transcutaneous electrical nerve stimulation (TENS), back braces, and physical agents is unproven Epidural injections may provide improved pain reduction short term Spinal injections are not recommended for initial care of patients with low back pain without radiculopathy + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Approximately 80% of episodes of low back pain resolve within 2 weeks and 90% resolve within 6 weeks Better prognosis when there is an anatomic lesion that can be corrected and when there are neurologic symptoms +++ Complications ++ Depending on the surgery performed, possible complications include Persistent pain Surgical site pain, especially if bone grafting is needed Infection Neurologic damage Non-union Cutaneous nerve damage Implant failure Deep venous thrombosis Death +++ When to Refer ++ Patients with the cauda equina syndrome Patients with cancer, infection, fracture, or severe spinal deformity Patients who have not responded to conservative treatment + References Download Section PDF Listen +++ + +Arnold E et al. The effect of timing of physical therapy for acute low back pain on health services utilization: a systematic review. Arch Phys Med Rehabil. 2019 Jul;100(7):1324–38. [PubMed: 30684490] + +Barrey CY et al; French Society for Spine Surgery. Chronic low back pain: relevance of a new classification based on the injury pattern. Orthop Traumatol Surg Res. 2019 Apr;105(2):339–46. [PubMed: 30792166] + +Bydon M et al. Degenerative lumbar spondylolisthesis: definition, natural history, conservative management, and surgical treatment. Neurosurg Clin N Am. 2019 Jul;30(3):299–304. [PubMed: 31078230] + +Chan AK et al. Summary of guidelines for the treatment of lumbar spondylolisthesis. Neurosurg Clin N Am. 2019 Jul;30(3):353–64. [PubMed: 31078236] + +Galliker G et al. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags—a systematic review. Am J Med. 2020 Jan;133(1):60–72. [PubMed: 31278933] + +Johnson SM et al. Imaging of acute low back pain. Radiol Clin North Am. 2019 Mar;57(2):397–413. [PubMed: 30709477] + +Karsy M et al. Surgical versus nonsurgical treatment of lumbar spondylolisthesis. Neurosurg Clin N Am. 2019 Jul;30(3):333–40. [PubMed: 31078234] + +Lemmers GPG et al. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019 May;28(5):937–50. [PubMed: 30796513] + +Rigoard P et al. Optimizing the management and outcomes of failed back surgery syndrome: a consensus statement on definition and outlines for patient assessment. Pain Res Manag. 2019 Feb 18;2019:3126464. [PubMed: 30911339] + +Tucker HR et al. Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review. Br J Sports Med. 2019 Mar 22. [Epub ahead of print] [PubMed: 30902816] + +Urits I et al. Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. 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