It’s a Monday morning and you open the electronic medical record to see a slew of patients scheduled with everyone’s favorite chief complaint: low back pain.
As you scroll through your schedule, you begin risk stratifying patients by age, complaint, duration, and medical history.
With more and more Americans becoming sedentary, back pain has become an epidemic, not dissimilar to that of diabetes or heart disease. The simple fact is, the more we sit, the more back pain we have.
It is important for clinicians to be able to be able to determine which patients warrant immediate work up, what symptoms are red flags, and how to manage the standard, uncomplicated musculoskeletal back pain.
Should we be worried about:
- The 60 year old who “pulled something while raking leaves”?
- The 82 year old who “heard a pop when grabbing a jug of milk”?
- The 32 year old with “one hour of back stiffness every morning”?
This article will review musculoskeletal back pain causes, presentation, exam, work up, and treatment, while distinguishing those patients who need a more aggressive work up.
A Background On Back Pain
Back pain is one of the most frequently encountered conditions among primary care, urgent care, and emergency medicine.
Each year, patients suffering from back pain account for millions of visits and represent billions of dollars in time off from work. This makes it essential for any provider to feel comfortable working up and treating back pain.
By definition, acute back pain lasts less than 6 weeks. Subacute back pain lasts between 6 weeks and 3 months; back pain only becomes “chronic” if it lasts longer than 3 months.
In the vast majority of back pain, a definitive cause is not elicited. However, reassurance that the majority of back pain resolves in 4 to 6 weeks should be provided to patients.
Risk Stratifying Low Back Pain
Risk factors for low back pain are multiple:
- Increasing age
- Sedentary lifestyle
- Cigarette smoking
Risk factors for acute back pain include active lifestyle, repetitive movements, poor posture, and poor lifting techniques.
Get a Good History
As with any chief complaint, the pneumonic OPQRST can be used to assess the length, duration, quality, severity, and other factors related to the back pain.
It is important to assess radicular symptoms, as pain starting in the back and radiating down the leg could be related to sciatica or nerve root irritation.
Patients may have exacerbations of chronic back pain, therefore it is important to note previous episodes, and whether symptoms are stable, new, or worse than previous.
The presence of numbness and tingling should clue the clinician in to radicular symptoms from nerve involvement. Weakness in the lower extremity is not normal for mechanical back pain.
It is important to note how far radicular symptoms travel, as this can indicate the level of nerve involvement. Past medical, family, social, and psychological history should always play a role in an accurate and thorough history.
Performing The Physical Exam in The Low Back Pain Patient
Performing a thorough exam is also paramount. Observing the patient walk into the exam room is helpful.
One should assess gait abnormalities, toe walking, and heel walking to look for nerve involvement. Range of motion, including flexion, extension and lateral bending of the spine should be assessed.
The straight leg raise can help determine if there is a herniated disc involved.
The Hoover test can help differentiate between organic and non-organic causes of back pain.
The FABER test can be helpful to assess for sacroiliac joint pathology.
Palpation of the back and spine is important to determine the focus, or area of tenderness. Pain with palpation over vertebrae is not normal and likely should warrant imaging to rule out fracture.
Pain with palpation over the paraspinal muscles or muscular spasm should alert the clinician to muscle strain.
A focused and thorough neurologic exam is extremely important. It should be noted that mechanical or musculoskeletal back pain should have a normal neurologic exam.
The neurological exam should focus on strength testing below the lumbar spine, deep tendon reflexes, sensation. Any weakness, loss of sensation, or dysesthesia should be worked up accordingly.
Low Back Pain Red Flags
As with any condition, it is important to focus on red flags which would warrant further work up.
The vast majority of low back pain does not need imaging unless the condition has been present greater than 6 weeks, however exceptions are important to note.
Recent trauma should warrant concern for fracture. Accompanying bony tenderness warrants imaging.
Neurologic deficits, such as saddle anesthesia, or bowel or bladder incontinence should raise suspicion for cauda equina syndrome, which may necessitate an emergent MRI.
Night pain, fever, sweats, or weight loss should cause concern for malignancy.
Patients who are greater than 70 years at onset should be worked up more aggressively.
Patients with a history of osteoporosis or chronic corticosteroid use can suffer from fragility fractures fairly easily. In some cases, the history may show something trivial, such as “picking up a gallon of milk” or sneezing.
Young males in their 20s or 30s, with an hour or two of stiffness in the morning, should be worked up for ankylosing spondylitis, a rare disorder that causes a “bamboo like” thickening of the spine.
Treating Low Back Pain
Once the zebras and more concerning causes of back pain have been ruled out, one can discuss treatment of back pain with the patient.
The hallmark of the management of acute flare ups of back pain includes both acetaminophen and NSAIDs to help with inflammation.
Heat or ice may be helpful depending on whether there is bony or muscle tenderness.
Intramuscular injections of ketorolac can be used to offer acute relief. Patients with muscle spasms or muscle strain may benefit from short courses of muscle relaxants, such as cyclobenzaprine, tizanidine, or baclofen.
In the acute setting, a judicious use of narcotics may help manage acutely severe pain, however many institutions recommend that there is no role for narcotics in the management of back pain.
It is important not to prescribe bed rest, as this can prolong recovery and has not been shown to be helpful.
Patients with subacute or chronic back pain may benefit from a daily anti-inflammatory medicine such as naproxen or meloxicam.
As always, the patient’s liver and kidney function should be taken into consideration. Routine use of NSAIDs and/or not following the given recommended doses could result in GI upset, ulcer, or bleeding.
Other modalities that can be helpful for back pain include physical therapy, chiropractic care, yoga, and massage therapy.
Patients not responding to conservative treatment or those suffering from frequent exacerbations may benefit from pain management referral.
It is important to counsel patients that back pain that is chronic in nature must be managed like any other chronic disease, with daily care to muscle stretching, strengthening exercises, and anti-inflammatory use to help prevent flare ups.
Back pain is a very common entity encountered across multiple specialties. Clinicians should focus on stratifying patients into those with mechanical back pain versus those presenting with red flags who require more workup.