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For further information, see CMDT Part 41-03: Spine Problems

Key Features

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


  • 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

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 ...

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