low back pain

1. Approach to the patient
with Low Back Pain
in Primary Care

2. Objectives
Differentiate between concerning and non-concerning
causes for acute low back pain
 Identify historical red flags
 Identify examination red flags
Briefly review evidence-based treatment options for
low back pain

3. Acute Low Back Pain
Easy Visit??? Frustrating Visit???

4. Acute Low Back Pain
Easy
 Usually not serious
 Limited management
options
 Often quick exam
Frustrating
 Difficult patients
 Limited management
options
 Can feel unsatisfying

5. Differential Diagnosis:
30 seconds
 List differential diagnosis for Low back pain
30 seconds
 List differential diagnosis for “bad” causes of Low back
pain

6. Differential Diagnosis of Low Back Pain
 Mechanical low back pain (97%)
 Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar muscles; some
radiation to buttocks
 Degenerative disk or facet process (10%) Localized lumbar pain; similar
findings to lumbar strain
 Herniated disk (4%) Leg pain often worse than back pain; pain
radiating below knee
 Osteoporotic compression fracture (4%) Spine tenderness; often
history of trauma
 Spinal stenosis (3%) Pain better when spine is flexed or when seated,
aggravated by walking downhill more than uphill; symptoms often
bilateral
 Spondylolisthesis (2%) Pain with activity, usually better with rest;
usually detected with imaging; controversial as cause of significant
pain

7.  Nonmechanical spinal conditions (1%)
 Neoplasia (0.7%) Spine tenderness; weight loss
 Inflammatory arthritis (0.3%) Morning stiffness,
improves with exercise
 Infection (0.01%) Spine tenderness; constitutional
symptoms

8.  Nonspinal/visceral disease (2%)
 Pelvic organs—prostatitis, pelvic inflammatory disease,
 endometriosis
 Lower abdominal symptoms common
 Renal organs—nephrolithiasis, pyelonephritis Usually
involves abdominal symptoms; abnormal urinalysis
 Aortic aneurysm - Epigastric pain; pulsatile abdominal
mass
 Gastrointestinal system—pancreatitis, cholecystitis, peptic
ulcer Epigastric pain; nausea, vomiting
 Shingles – (zona) Unilateral, dermatomal pain; distinctive
rash

9. Differential Take-Home
 97% is mechanical
 4% Herniated disc (95% L4-L5; L5-S1)
0.2% Cauda Equina
2% Non-back sources
1% Cancer and Infection

10. Our Job…
In 15 minutes, differentiate benign from serious causes
of low back pain

11. We Need a Strategic Timeline
Good history – 3-5 minutes
Focused Exam – 2-4 minutes
Treatment options and pt education – 4-5 minutes

12. The Case Begins:
87 yo M presents to clinic for back pain
Located mid to low back
Started about 3-4 days ago

13. Outline
List essential components of a LBP history, including
Red flags
Review Physical Examination for LBP
 Identify Red flags
Review proper indications for lab and imaging
Discuss acute management options

14. General Questions
Onset
Location
Mechanism of Injury
Radiation
Positional change
Numbness, tingling
Weakness

15. Red Flags
Age > 50
IV drug use
Hx/o cancer
Prolonged steroid use
Osteoporosis
Distal numbness
Saddle anestesia
Bowel or bladder loss
Fever
Trauma
Unexplained wt loss
Pain at rest/night
Weakness

16. Diagnoses & Red Flags
Cancer
Age > 50
History of Cancer
Weight loss
Unrelenting night
pain
Failure to improve
Infection
 IVDU
 Steroid use
 Fever
 Unrelenting night
pain
 Failure to improve
Fracture
Age >50
Trauma
Steroid use
Osteoporosis
Cauda Equina
Syndrome
Saddle anesthesia
Bowel/bladder
dysfunction
Loss of sphincter control
Major motor weakness

17. Diagnoses & Red Flags
Cancer
Age > 50
History of Cancer
Weight loss
Unrelenting night
pain
Failure to improve
Infection
 IVDU
 Steroid use
 Fever
 Unrelenting night
pain
 Failure to improve
Fracture
Age >50
Trauma
Steroid use
Osteoporosis
Cauda Equina
Syndrome
Saddle anesthesia
Bowel/bladder
dysfunction
Loss of sphincter control
Major motor weakness

18. Our case
Red flags
 Age 87
 Hx/o Non-Hodgkin’s
 Remission for the past 4 years

19. Our Case
No hx/o back problems
No trauma
No radiation
No focal weakness
No numbness or tingling
No change in bowel or bladder function

20. Outline
List essential components of a LBP history, including
Red flags
Review Physical Examination for LBP
 Identify Red flags
Review proper indications for lab and imaging
Discuss acute management options

21. 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

22. Six-Point MSK Exam
Inspection
Palpation
ROM
Strength
Neurovascular
Special Tests

23. Inspection
Ensure
No obvious deformities
No erythema
Skin lesions (Zoster)

24. Palpation
Soft Tissue
4 clinical zones
 Paraspinal muscles
 Gluteal muscles
 Sciatic area
 Anterior
abdomen/abdominal
wall
Bones
 Primarily palpating
spinous processes and
facets

25. Neurologic
Testing
Sensation
Strength
Reflexes

26. Special Tests
Tests to stretch spinal cord or
sciatic nerve
Tests to stress the sacroiliac joint

28. Straight leg raise
Looking for lumbar disk herniation
Performed supine for best sensitivity
Positive when radiating pain observed at 30-70 degress
of hip flexion
Very high sensitivity, but low specificity
Should also do the crossed-leg straight leg raise
 Positive when they have pain when you lift and adduct
the opposite leg

29. FABER test:
Flexion
A-
Bduction
External
Rotation

30. Tests
Lab
 Based on clinical picture
 Think Red Flags
Imaging
 XR
 CT
 MRI

31. Imaging Guidelines
Choice 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

32. Outline
List essential components of a LBP history, including
Red flags
Review Physical Examination for LBP
 Identify Red flags
Review proper indications for lab and imaging
Discuss acute management options

33. Back pain treatment
NSAIDs (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

34. Treatment
Pain relievers
 Both opioid and non-opioid
Steroids
 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

35. Treatment
Exercise 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 mixed
Ice/Heat (B)
 Equivalent in a Cochrane review

36. 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.

37. 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

38. 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

39. Conclusions
History is very important
 Don’t forget your red flags
Look for focal findings on exam
There is evidence to help with treatment
Pt’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

40. References
Evaluation 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.

41. Questions???