Evaluation and Management

of Acute Low Back Pain

Zafar Iqal
Abbasi Shaheed Hospital
Karachi
 Acute Low Back Pain
 Affects up to 90% of the US population at
some point in their life
 It is second only to URI-s for symptom-
related visits to primary care physicians
 It is the most common cause of work related
disability in persons under the age of 45 and
the second most common cause of temporary
disability for all ages
 It costs over 60 billions annually
Acute Low Back Pain
 It is a self-limiting condition that usually
resolves in up to six weeks
 In approximate 80% of the cases no clear
etiology is ever determined
 There is a small subset of patients in
whom LBP signals a life-threatening
disease or a disorder that require
immediate attention
Low Back Pain
 Is defined as pain localized between the
lower rib cage and the gluteal folds often
extending or radiating into the thighs. It
can be subclassified as:
 Acute if lasting less than 6 weeks
 Subacute if lasts between 6 and 12 weeks
 Chronic if duration of the pain is longer than
12 weeks
Low Back Pain Generators
1. Osseous: vertebral body, pedicles,
lamina, facets, spinous and transverse
processes of the vertebras
2. Neuroanatomic (frequent pain
generator)
3. Supporting structures:
• Intervertebral disc (most frequent pain gen.)
• Ligaments (ALL, PLL, L. flavum, facet
capsules, supraspinous, intraspinous)
Differential Diagnosis
 Mechanical Low Back or Leg Pain
97%
 Nonmechanical Spinal Conditions
1%
 Visceral Diseases
Differential Dx: Mechanical
Low Back or Leg Pain (97%)
 Lumbar strain/sprain  Traumatic fracture
70% <1%
 Degenerative process  Congenital
10% disease:severe kyphosis
 Herniated discs 4% or scoliosis, transitional
vertebrae <1%
 Spinal stenosis 3%
 Spondylolysis
 Compression fx 4%
 Internal disc disruption
 Spondylolisthesis
2%  Presumed instability
Differential Dx:Nonmechanical
Spinal Conditions (1%)
 Neoplasia 0.7%  Inflammatory arthritis
 multiple myeloma 0.3%
 mets  ankylosing spondylitis
 lymphoma/leukemia  psoriatic spondylitis
 spinal cord tumors  Reiter’s syndrome
 retroperitoneal tumors  Inflammatory bowel
 primary vert. Tumors disease
 Infection 0.01%
 Paget’s disease
 osteomyelitis  Scheuermann’s disease
 septic diskitis
 paraspinous abscess
 shingles
Differential Dx: Visceral
Disease (2%)
 Disease of pelvic  Aortic aneurysms
organs  Gastrointestinal
 prostatitis
diseases
 endometriosis
 pancreatitis
 chronic PID
 cholecystitis
 Renal disease
 nephrolithiasis
 penetrating ulcer
 pyelonephritis
 perinephric abscess
Red Flags in the History
 Age – less than 18 or more than 50
 Trauma – even minor if elderly/steroid rx
 Cancer
 Fever, chills, night sweats
 Weight loss
 IVDA
 Recent GI/GU procedures
 Severe and unremitting pain
 Severe or progressive neurological deficit
Red Flags in the History
 Benign back pain is usually dull,
achy pain which is exacerbated by
movement but improves with rest
 Red flags for tumor or infection is
pain that is worsen at night and
awakes patient from sleep, not
improved by rest or is unrelenting
despite appropriate analgesics
Red Flags in the History
 Pain that is worsen with prolonged
sitting, coughing and Valsalva
maneuver often occurs with disk
herniation
 Patients with benign acute LBP
rarely have associated neurological
deficits. Any such complaint is a “red
flag”
 Physical Examination -
Inspection
 Vital signs – fever is a red flag for infection; is
present in 27% of TB OM, 50% of pyogenic OM and
in 87% of epidural abscesses
 Patients with benign back pain prefer to remain still.
Severe pain should rise concerns for infection,
nephrolithiasis or aortic aneurysm
 Observe patient’s gait and ability to heel walk
(testing dorsiflexion-L4 and L5 roots) and toe walk
(testing plantar flexion – S1 root)
Physical Examination -
Inspection
 Back should be exposed and observed for
spasm, erythema and edema
 Patients with anterior problems
(degenerated disk) usually have
extension preference; those with
posterior mechanical problems
(spondylosys or spondylolysthesis) have
flexion preference
 Physical Examination -
Palpation
 Spine and paraspinal structures should be palpated.
Point tenderness usually indicates ligamentous
disruption or local destruction by tumor or fracture
 Straight leg test – a positive test reproduces
radicular pain below the knee and along the path of a
nerve root (L5, S1) at 30- to 70- degree elevation
from supine. Is approximate 80% sensitive for disk
herniation. Approximately 80-90% of all herniated
disks occur at the level of either L4-5 or L5-S1
Physical Examination –
Neurological Evaluation
 Lower extremity strength and
sensation (dermatomal distribution)
 Reflexes - Patellar (L3-L4)

- Achilles (S1)
- Babinski (upper motor)
 Associated neurological deficits –
urinary and bowel retention or
incontinence
Red Flags in the Physical
Examination
 Fever
 Point tenderness on percussion
 Anal sphincter laxity
 Perianal sensory loss
 Motor weakness
 Positive straight leg raise test
Diagnostic Testing
 When there are no red flags a good
history and physical exam should
suffice
 Lab tests - if tumor or infection is
suspected a CBC, ESR, CRP should be
obtained
 Radiography – are necessary only if there is
concern for fracture (history of trauma),
malignancy or rheumatologic disease. AP
and Lat views should suffice. If films are
negative but concern still exists MRI or CT
should be obtained
Diagnostic Testing - MRI
 Is the gold standard test for compressive
lesions of the spinal cord or the cauda
equina, infections or disk herniation
 Allows evaluation for disk degeneration
and nerve root entrapment
 Excellent screening for bone marrow
replacement processes
 If only disk herniation is suspected, it can
be delayed for 6 weeks
 Diagnostic Testing – CT
 Is the modality of choice to visualize bony
details especially subarticular region
 Very useful in setting of trauma to
evaluate the stability of the spinal column
and integrity of the spinal canal
 Useful for vertebral OM but can miss
epidural abscesses
 Use of myelography prior to CAT scanning
will provide excellent intratechal detail
Diagnostic Testing
 Bone Scan – can help identify
metastatic cancer, infectious
processes and stress fractures
 Electromyography/Nerve Conduction
Velocity - can be useful to
investigate radiculopathy. Have little
use in nonradicular pain syndromes
Treatment of Benign Acute
LBP
 About 80% of acute LBP sufferers will
completely recover in 4 weeks
 Several studies found that patients who
resumed their activity recovered faster than
those who stayed in bed for 2 days
 Active exercise has not been shown to be
beneficial during the acute stage of back pain
 Patients should resume normal daily activities
but curtail those that exacerbate the pain
Analgesia
 The mainstays of therapy are NSAIDs,
acetaminophen, and opiate analgesics
 Acetaminophen has proven efficacy
comparable with NSAIDs with fewer side
effects. Usual dose is 650 to 1000mg Q 6
hrs
 Most nonsteroidals are equally efficacious.
Lowest dose should be tried. If there is
concern about GI bleeding can be
combined with misoprostol or PPI
Analgesia
 COX-2 inhibitors are effective, have
fewer side effects than regular NSAIDs
but the cost is very high
 A common approach is a combination
of acetaminophen 650 to 1000 mg QID
with ibuprofen 800 mg TID or
naproxen 500 mg BID
 Ketorolac has not been shown to be
superior to other oral NSAIDs
Analgesia
 Opiate analgesics (codeine) should be
prescribed for more severe pain in
combination with acetaminophen or
NSAIDs
 Oxycodone and hydrocodone should be
avoided because of higher dependency
potential
 Should be prescribed only for a short
period of time
Analgesia
 Muscle relaxants (methocarbamol,
cyclobenzaprine, diazepam) are especially
indicated in treating LBP associated with
spasm
 Are more effective than placebo in treating
LBP but no better than NSAIDs
 Can produce drowsiness
 Does not seem to have a synergistic effect
with acetaminophen or NSAIDs
Back Manipulation
 Is one of the most controversial
treatments for LBP
 Most studies have found that while it may
have some limited short term benefit the
lasting results are unproven
 A recent meta-analysis of 39 RCT-s did
not show back manipulation to be more
effective than conventional treatment
Other Physical Modalities
 Other treatment modalities include
traction, ultrasound, cutaneus laser
therapy, massage, accupuncture and
electrical nerve stimulation. None of these
has been shown to improve recovery rate
from acute LBP
 Heat and ice therapy is marginally
effective in reducing pain and is very
inexpensive
Preventive Measures
 Start a program of regular exercises
beginning with low stress aerobic
exercises followed in a few weeks by
exercises to condition specific trunk
muscles
 Loss of excess of weight
 Regular walking and swimming
 Avoidance of high impact exercises for at
least several months after the acute LBP
Epidural Compression
Syndrome
 Includes spinal cord compression,
cauda equina syndrome and conus
medularis syndrome
 Except for the level of the
neurological deficit, the presentation
of these syndromes is similar
 The initial evaluation and
management is also similar
Epidural Compression
Syndrome
 Is a medical emergency because of the
catastrophic neurological loss that can
develop
 Is caused by pressure being exerted on
the cord or cauda equina from a space
occupying lesion – tumor, abscess, disk
herniation or traumatic compression
Epidural Compression
Syndrome
 LBP might not be the dominating complaint
 Leg pain is more frequent
 Symptoms are usually bilateral and usually
a combination of motor, sensory and
autonomic dysfunctions
 Patients can experience constipation or
incontinence of the bowel, retention or
incontinence of the urinary bladder
Epidural Compression
Syndrome
 Saddle anesthesia
 Major motor or sensory loss is often
noted
 Patients with these symptoms
should be treated emergently and
should be assumed they have spinal
cord injury until proven otherwise
Epidural Compression
Syndrome
 10 –100 mg of dexamethasone
should be administered iv because it
might reduce the progression of
deficits and alleviate pain
 Emergent MRI of the region
according to the level of the
neurological deficits
 Immediate specialist consultation
Epidural Compression
Syndrome
 Outcomes depend on the neurologic
deficit at presentation
 Patients paraplegic at presentation are
unlikely to walk again; those who were
too weak to walk alone but not paraplegic
had a 50% chance of walking again.
Those who were ambulatory remained so
 Of the patients catheterized for
denervated bladder 80% did not recover
bladder function
Cancer
 History sensitivity specificity
 Age > 50 0.77 0.71
 previous history 0.31
0.98 of cancer
 failure to improve 0.31
0.90 in 1 mo. of therapy
 no relief -bed rest >0.90 0.46
 duration > 1 mo 0.50 0.81
 age >50 or cancer hx or 1.00 0.60
unexplained wt loss or
failure of conservative tx.
 Insidious onset
 constitutional symptoms
Infection
 Intravenous drug abuse, UTI, or skin
infection in 40%
 also,
 immune suppression
 insidious onset

 previous surgery

 constitutional symptoms
Compression fracture
 History sensitivity
specificity
 age >500.84 0.61
 age >70 0.22 0.96
 trauma 0.30 0.85
 corticosteroid use 0.06 0.995

 in elderly trauma can be minor

Herniated Disc
 Sciatica
• sensitivity 0.95 specificity 0.88

• aching pain in buttock-- paresthesias radiating

into posterior thigh and calf or posterior lateral
thigh and lateral foreleg

• pain worsened by flexion

• aggravated by sneeze, cough, Valsalva
Ankylosing Spondylitis
 History sensitivity
specificity
 age at onset <40 1.00 0.07
 pain not relieved by supine 0.80 0.49
 morning back stiffness 0.64 0.59
 pain duration >3 months 0.71 0.54
 4 of 5 questions above positive 0.23 0.82
also: improved by exercise

 worse after rest, heat helps

Spinal Stenosis
 Pain beyond back to buttock,thigh or
lower legs
 “Neurogenic claudication”
 Worse with extension of LS (stand/walk)
 Improves with flexion (sitting)
 Average age of surgery-55 (4 yrs of
sx’s)
Cauda equina syndrome
 Bladder dysfunction
 Saddle anesthesia
 Major limb motor weakness
Factors predisposing to
Repetitive strain injury
 Reaching overhead  Carrying a large wallet in
repetitively the back pocket
 standing or working on  leg length discrepancy
concrete w/o cushioned  recent weight gain
shoes  excessive coughing
 repetitive rotating of trunk
during prolonged tasks  high risk occupations
 heavy lifting chores  miscellaneous labor
 lifting inappropriately
 garbage collection
 warehouse work
 sleeping on the abdomen  nursing
 beginning weightlifting
 using a rowing machine
 driving prolonged periods
to work
Predicting Chronic Pain
 Clinical factors
 previous episodes of BP
 multiple
musculoskeletal
complaints
 hypochondriasis
 etoh, drugs, tobacco
 Pain experience
 rate pain as severe
 blame others for pain
 legal issues or
compensation
 Premorbid factors
 rate job as physically
demanding
 believe they will not be
working in 6 months
 don’t get along with
coworkers
 near to retirement
 spouse to supportive
 unmarried or multiple
x’s
 low socioeconomic
 troubled childhood
LUMBAR SPINE
 Range of Motion
 Flexion (>60 degrees)
 floor to finger measurement
 extension (>25 degrees)
 lateral bending (>25 degrees)
Dermatomes
 L3
 L3/L4- quadriceps muscle
 sit on table and attempt to straighten
bent knee against resistance
 sensation - oblique band on anterior
thigh-immediately above knee cap
 L4
 Tibialis anterior-offer resistance to
dorsiflexion and inversion of foot
 Patellar reflex
 sensation - medial leg and foot
 L5
 Extensor hallucis longus-resist dorsiflexion
of great toe or heel walk (foot drop)
 Gluteus medius - resist abduction of leg
 No reflex
 sensation- dorsum of foot
 98% L4/5 or L5/S1 herniations-affects L5
and S1 levels
 S1
 Peroneus longus and brevis-oppose
plantar flexion/eversion of foot by
pushing on 5th metatarsal with palm
of hand
 inability to walk on toes
 Achilles reflex
 sensation-lateral malleolus and
lateral/plantar surface of foot
 Straight leg raising
 Pain in leg, buttock, or back at 60
degrees or less of leg elevation
 usually worsened by dorsiflexion of
ankle and relieved by flexion of knee
and hip
 Sensitivity 0.80 Specificity
0.40
 Crossed and Reverse
Straight Leg Raising
 Crossed
 pain in contralateral, symptomatic leg when
asymptomatic leg raised
 sensitivity 0.25 specificity 0.90

 Reverse
 lies prone or on side and thigh is extended
one at a time; pain over involved nerve root
 usually L3 or L4 irritation
 PE -Lumbar disc herniation
 Test sensitivity specificity
 ipsilateral SLR 0.80 0.40
 crossed SLR 0.25 0.90
 impaired ankle reflex 0.50 0.60

 ankle plantar flex weak 0.06 0.95

 great toe exten weak0.50 0.70

 ankle dorsiflex weak 0.35 0.70

 Schober’s test
 Technique
• Patient stands erect with normal posture
• Identify level of posterosuperior iliac spine
• Mark midline at 5 cm below iliac spine

• Mark midline at 10 cm above iliac spine

• Patient bends at waist to full forward flexion

• Measure distance between 2 lines (started 15 cm apart)
 Interpretation
• Normal: distance between 2 lines increases to >20 cm
• Abnormal: distance does not increase to >20 cm
• Suggests decreased Lumbar spine range of motion

• May suggest Ankylosing Spondylitis

 Other tests
 Milgram test- hold heels 2 in. off table for 30 sec., if
can hold intrathecal pathology ruled out
 FABER test- laying supine, place foot of involved side
on opposite knee, press on knee and opposite hip, if
pain may be SI joint pathology
 Pelvic rock- hands on iliac crests and ant sup iliac
spines then compress pelvis toward midline, if pain may
be sacroiliac pathology
 Hoover test- for malingering, pt should bear down
with opposite heal if making attempt to raise leg
 Must do Exam
 Straight leg raising test
 Dorsiflexion strength of the ankle
and the great toe
 Light touch sensation of the medial
(L4), dorsal (L5), and lateral (S1)
aspect of the foot
 ankle reflexes
 Waddell’s signs
 Overreaction during the exam
 Simulated testing
 positive when pain reported with axial loading or rotation with
pelvis/shoulders in same plane
 Distracted testing
 test straight leg raise while distracted when sitting

 Superficial, nonanatomical or variable tenderness

 Nonanatomical motor or sensory disturbances
 sensory loss does not follow dermatome or entire leg is numb or when
“ratchety” giveway on strength testing

 3/5 = likely psychogenic component

 2/5 = correlates with poor surgical outcome, not rehab outcome
 Summary
 Many causes-most common
strain/sprain
 Know the red flags
 Examine the patient
 Waddell’s signs