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A 51-year-old woman presents to your clinic with a complaint of low back pain, which began acutely 2 weeks earlier, 1 day after a 10-km run. The pain is described as achy, intermittent, and located in the central region of her low back. It is associated with an occasional electrical sensation shooting down her left leg. The pain is aggravated by rolling over in bed, prolonged sitting, and running; it is relieved by rest, changing positions, and ibuprofen.

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  • What additional questions would you ask to learn more about her low back pain?
  • How do you classify low back pain?
  • How do you determine whether her symptoms are worrisome for a serious neurologic, systemic, or nonspinal condition?
  • What features suggest a better or worse prognosis for developing a chronic disabling condition?
  • How do you determine whether further diagnostic or therapeutic intervention in indicated?

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Low back pain (LBP) is a common reason for office appointments in the United States, accounting for 2% of all visits.1 Approximately 70% of adults will have an episode of LBP during their lifetime, and 25% to 40% will have multiple episodes.1,2 It is also one of the most costly conditions in terms of time lost from work and decreased productivity while at work.2,3 Additionally, the prevalence of chronic LBP seems to be increasing. In North Carolina, the prevalence of persistent back pain that interfered with function increased from 3.9% in 1992 to 10.2% in 2006.3 A small minority of patients with chronic disabling LBP account for a disproportionate share of the healthcare costs. Fortunately, most cases of acute LBP follow a benign, self-limited course with substantial improvement or resolution within the first 4 to 8 weeks.4 The practitioner must identify worrisome features suggesting a serious etiology or risk of developing a chronic disabling condition.

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Acute LBPAn episode of back pain lasting < 3 months in duration, most commonly < 2 weeks.
Ankylosing spondylitisInflammatory disorder affecting primarily the axial skeleton with symptoms usually beginning in late adolescence or early adulthood, the hallmark being sacroiliitis.
Cauda equina syndromeAcute compressive radiculopathy of the sacral nerve roots that comprise the cauda equina. Symptoms include severe back pain, urinary retention or urinary and fecal incontinence, saddle anesthesia, and leg weakness. Arises most commonly from a large midline disk herniation but can complicate any process that leads to spinal canal narrowing at the level of the cauda equina (eg, tumor, spinal stenosis).
Chronic LBPAn episode of back pain lasting > 3 months in duration.
MyelopathyPathologic disturbance of spinal cord function manifested by peripheral muscle weakness, increased muscle tone, spasticity, and hyperreflexia.
RadiculopathyA nonspecific term referring to the compression or irritation of a nerve root and manifesting in symptoms of pain, weakness, or sensory loss in the distribution of the nerve.
Neurogenic claudication (pseudoclaudication)Pain typically located in the low back, buttocks, and proximal thighs associated with spinal stenosis. Pain is ...

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