Low Back Pain
last authored: Jan 2012, David LaPierre
last reviewed:
Introduction
The majority of back pain is mechanical or degenerative in nature. However, there are many life-and limb-threatening causes of back pain as well, and it is important to consider and exclude these in patients who present with this condition.
The Case of...
Differential Diagnosis
The majority of back pain is mechanical, which includes the following:
Spinal stenosis:
Cauda equina syndrome neoplasm: primary or metastatic trauma ankylosing spondylitis diskitis or osteomyelitis |
epirudal abscess abdominal aortic aneurysm pyelonephritis renal stones pancreatitis malingering |
History and Physical Exam
- history
- physical exam
History
Red flags:
- bowel or bladder dysfunction
- anaesthesia
- constitutional symptoms/malignancy
- paresthesias
- age >50 of onset
- IV drug user
- neuromotor deficits
History of back pain should begin with OPQRST:
- onset
- provoking/palliating factors
- quality
- radiating
- severity
- timing
Other factors should include:
- weakness or numbness
- impact on ADLs and IADLs
- worse with standing and walking (?spinal stenosis)
- morning stiffness (ankylosing spondylitis)
- changes in bowel or bladder habits or sexual function (cauda equina syndrome)
Review of systems
- fever, weight loss, sweats (AS, malignancy)
- other joint involvement
- eye pain, redness, or photophobia
- skin rash (eg psoriasis)
- gastrointestinal manifestations of inflammatory bowel disease
- balanitis
Past medical history
- malignancy
Family history
- arthritis
- inflammatory bowel disease
Social history
- IV drug use
- TB risk factors
Physical Exam
The back exam is outlined here.
Pain that is worse with flexion and relieved with extension suggests a disc origin.
Pain that is worse with extension suggests fact joint involvement.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Management
Physical or therapeutic exercise
Focus on active, rather than passive, exercise
medications
acetaminophen
NSAIDs
weak opioids, TCAs
tramadol
strong opioids
duloxetine (Skljarevski et al, 2010).
Pathophysiology
For example, with disc herniation, pain is initially neuropathic, but over time, neuropathic pain
Resources and References
Topic Development
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