Approach to the patient with
Low Back Pain in Primary Care
ObjectivesDifferentiate between concerning and non-
concerning causes for acute low back painIdentify historical red flagsIdentify examination red flags
Briefly review evidence-based treatment options for low back pain
Acute Low Back PainEasy Visit??? Frustrating Visit???
Acute Low Back PainEasy
Usually not serious Limited
management options
Often quick exam
Frustrating Difficult patients Limited
management options
Can feel unsatisfying
Differential Diagnosis:30 seconds
List differential diagnosis for Low back pain30 seconds
List differential diagnosis for “bad” causes of Low back pain
Differential Diagnosis of Low Back PainMechanical low back pain (97%)
Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar muscles; some radiation to buttocksDegenerative disc or facet process (10%) Localized lumbar pain; similar findings to lumbar strainHerniated disc (4%) Leg pain often worse than back pain; pain radiating below kneeOsteoporotic compression fracture (4%) Spine tenderness; often history of traumaSpinal stenosis (3%) Pain better when spine is flexed or when seated, aggravated by walking downhill more than uphill; symptoms often bilateralSpondylolisthesis (2%) Pain with activity, usually better with rest; usually detected with imaging; controversial as cause of significant pain
Differential Diagnosis of Low Back PainNonmechanical spinal conditions
(1%)Neoplasia (0.7%) Spine tenderness; weight lossInflammatory arthritis (0.3%) Morning stiffness, improves with exerciseInfection (0.01%) Spine tenderness; constitutional symptoms
Differential Diagnosis of Low Back PainNonspinal/visceral disease (2%)
Pelvic organs—prostatitis, pelvic inflammatory disease,Endometriosis-Lower abdominal symptoms commonRenal organs—nephrolithiasis, pyelonephritis Usually involves abdominal symptoms; abnormal urinalysisAortic aneurysm - Epigastric pain; pulsatile abdominal massGastrointestinal system—pancreatitis, cholecystitis, peptic ulcer Epigastric pain; nausea, vomitingShingles – (zona) Unilateral, dermatomal pain; distinctive rash
Differential Take-Home 97% is mechanical
4% Herniated disc (95% L4-L5; L5-S1)
2% Non-back sources1% Cancer and Infection0.2% Cauda Equina
Our Job…In 15 minutes, differentiate benign from
serious causes of low back pain
We Need a Strategic TimelineGood history – 3-5 minutesFocused Exam – 2-4 minutesTreatment options and patient education – 4-
5 minutes
The Case Begins:
87 year old Mehmet bey presents to clinic for back pain
Located mid to low backStarted about 3-4 days ago
OutlineList essential components of a LBP history,
including Red flagsReview Physical Examination for LBP
Identify Red flagsReview proper indications for lab and
imagingDiscuss acute management options
General QuestionsOnsetLocationMechanism of InjuryRadiationPositional changeNumbness, tinglingWeakness
Diagnoses & Red Flags*Cancer
Age > 50History of
CancerWeight lossUnrelenting
night painFailure to
improve
Infection IVDU Steroid use Fever Unrelenting night
pain Failure to improve
FractureAge >50Trauma Steroid useOsteoporosis
Cauda Equina SyndromeSaddle anesthesiaBowel/bladder
dysfunctionLoss of sphincter
controlMajor motor
weakness
Diagnoses & Red FlagsCancer
Age > 50History of
CancerWeight lossUnrelenting
night painFailure to
improve
Infection IVDU Steroid use Fever Unrelenting night
pain Failure to improve
FractureAge >50Trauma Steroid useOsteoporosis
Cauda Equina SyndromeSaddle anesthesiaBowel/bladder
dysfunctionLoss of sphincter
controlMajor motor
weakness
Our caseRed flags
Age 87 Hx/o Non-Hodgkin’s
Remission for the past 4 years
Our CaseNo hx/o back problemsNo traumaNo radiationNo focal weaknessNo numbness or tinglingNo change in bowel or bladder function
OutlineList essential components of a LBP history,
including Red flagsReview Physical Examination for LBP
Identify Red flagsReview proper indications for lab and
imagingDiscuss acute management options
Physical Exam*Rule-out most concerning things
Concerning features Decreased strength Diminished reflexes Sensory loss
Reassuring features Paraspinal muscle
spasm Full strength No sensory deficits
Six-Point MSK ExamInspectionPalpationROMStrengthNeurovascularSpecial Tests
InspectionEnsure
No obvious deformitiesNo erythemaSkin lesions (Zoster)
PalpationSoft Tissue4 clinical zones
Paraspinal muscles Gluteal muscles Sciatic area Anterior
abdomen/abdominal wall
Bones Primarily palpating
spinous processes and facets
Neurologic Testing
SensationStrengthReflexes
Special TestsTests to stretch spinal cord or sciatic nerve
Tests to stress the sacroiliac joint
Straight Leg RaiseThe straight leg raise, also called Lasègue's
sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).
Straight leg raiseLooking for lumbar disk herniationPerformed supine for best sensitivityPositive when radiating pain observed at 30-
70 degress of hip flexionVery high sensitivity, but low specificityShould also do the crossed-leg straight leg
raise Positive when they have pain when you lift and
adduct the opposite leg
FABER test:To assess for the sacroiliac joint or hip joint being the source of the patient's pain If pain is elicited on the ipsilateral side anteriorly, it is suggestive of a hip joint disorder on the same side. If pain is elicited on the contralateral side posteriorly around the sacroiliac joint, it is suggestive of pain mediated by dysfunction in that joint.
FlexionA-BductionExternalRotation
TestsLab
Based on clinical picture Think Red Flags
Imaging XR CT MRI
Imaging GuidelinesChoice to do imaging based on:
Historical red flags Trauma, chronic steroid use = XRay Suspect abscess, cauda equina = MRI
Exam red flags New/severe sensory or strength loss = consider MRI
OutlineList essential components of a LBP history,
including Red flagsReview Physical Examination for LBP
Identify Red flagsReview proper indications for lab and
imagingDiscuss acute management options
Back pain treatmentNSAIDs (A)
Improve pain vs. placebo in controlled trials No difference between them NNT for 50% pain relief is 2-3
Muscle relaxants (A) Most beneficial in the first week Shown effective in trials Work best when combined w/ NSAIDs
TreatmentPain relievers
Both opioid and non-opioidSteroids
No benefit shown w/ orals Short-term benefit shown for epidural
Bed rest NO!!! Activity increases functional status and
decreases time missed from work and pain
TreatmentExercise plan
No benefit during the acute phase, but helpful afterwards for prevention in MSK back pain (although USPSTF is neither for nor against)
Massage Mixed evidence, but not harmful
Acupuncture Most good studies show no benefit, but overall
results are mixedIce/Heat (B)
Equivalent in a Cochrane review
Clinical recommendation and Evidence rating
In the absence of “red flag” findings or signs of cauda equina syndrome, four to six weeks of conservative care is appropriate for patients with acute low back pain. C
Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain. A
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series.
Clinical recommendation and Evidence rating
Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. A
Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain. C
Specific back exercises for patients with acute low back pain are not helpful. A
Clinical recommendation and Evidence rating
Heat therapy may be helpful in reducing pain and increasing function in patients with acute low back pain. B
Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care. B
ConclusionsHistory is very important
Don’t forget your red flagsLook for focal findings on examThere is evidence to help with treatmentPt’s w/ low back pain or sciatica w/o red flag
SYMPTOMS should try conservative management for about 6 wks prior to imaging or intervention
ReferencesEvaluation and Treatment of Acute Low Back
Pain. AAFP. 75(8), 2007.Acute Lumbar Disk Pain. AAFP. 78(7), 2008.When to Consider Osteopathic Manipulation.
JFP. 59(9), 2010.ACSM Primary Care Sports Medicine.Physical Exam of the Spine and Extremities.
Hoppenfeld, S. et al.
Questions???