Back pain is a common problem that affects up to 90% of the population. It can be classified as acute (less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks). Red flags on history and exam can indicate more serious underlying causes like cancer, infection, or fracture that require further evaluation. For nonspecific back pain without red flags, treatment focuses on analgesics, activity modification, and physical modalities. Referral is considered if red flags are present, pain persists after 4-6 weeks, or neurological deficits develop.

1. Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MD
Emergency PhysicianEmergency Physician
Khoula HospitalKhoula Hospital
Back Pain Made EZ!
Primary Health Care Physicians Wo

2. Epidemiology
Definitions/Classifiication
RED FLAGS +Interpretation
How to examine?
Testing
Specific conditions
Management
Overview

4. Epidemiology
Affects up to 90% of population at some point in
their lives
∼ 4% of emergency department visits
Highest economic burden after heart disease &
stroke
85% have no definite etiology
90% with nonspecific back pain symptoms resolve
within 1 month

5. Risk Factors
Increasing age
Heavy physical work (long periods of static work
postures, heavy lifting, twisting, and vibration)
Psychosocial factors (including work dissatisfaction
and monotonous work)
Depression
Obesity (BMI > 30)
Smoking
Drug abuse
History of headache

6. Definitions
Acute LBP = < 6 weeks
Subacute LBP = 6-12 weeks
Chronic LBP = > 12 weeks

7.  Nonspecific back pain (majority)
= localized
 Back pain + radiculopathy/sciatica
= radiating
 Back pain associated with another specific cause
= referred
Classification

8. Clinical Presentation
Ranges :
 mild (muscle spasm) → severe/unrelenting (epidural abscess)
NOT important → recognize a particular classic
presentation for various diseases
IMPORTANT → evaluate for the red flags
Identification of red flags will direct whether further
evaluation is required

10. Very Serious Pathology
Vascular
 AAA, Aortic Dissection (AD)
Malignancy
 Mets: breast, prostate, lung, kidney, thyroid
 Bone or spinal epidural metastasis (SEM)
Infectious Process
 Vertebral osteomyelitis ,Spinal epidural abscess
(SEA)
Spinal cord compressive syndromes (SCCS)
 Spinal epidural mets (SEM), central disc herniation,
SEA, spinal epidural hematoma

11. Less Serious Pathology
Spinal fractures
Spinal stenosis
Spondylolysis / spondylolisthesis
Regular disc herniations
 usually lateral and compress nerves on one side and
not the cord / cauda

12. Red Flags
History
Age <18,>50
>6 weeks
*Systemic complaints:
 fever/chills/night sweats
 undesired weight loss
 malaise
Trauma (minor in OP, elderly)
Cancer (0.7% → 9%)
Immunocompromise
IVDU

13. Red Flags

14. Red Flags
History
Think outside the box!
Resp- e.g. Pneumonia
GI- e.g. Pancreatitis
GU- e.g. Pyelonephritis
AAA

15. Historical Red Flags? What do
they mean?

16. Gradual onset of back pain
 Malignancy or infection usually progress over weeks to months
Age <18
 Congenital, spondylolysis/spondylolisthesis
Age >50
 AAA, malignancy, compression fracture
Thoracic back pain
 Aortic dissection, SEA, Vertebral osteomyelitis, malignancy
 Most common site of malignant spine lesions is thoracic spines
(accounts for 60% of cases)
History

17. History
Pain > 6 weeks
 Malignancy, infection, spinal stenosis, spondylolysis
Hx of trauma
 Fracture
 MVA in normal, fall in elderly/osteoporotic
Fever/chills/night sweats, weight loss
 Malignancy or infection
Pain worse when supine
 Malignancy or infection

18. History
Pain worse at night
 Malignancy or infection
Pain despite good analgesics
 Malignancy or infection
Hx of malignancy
 Hello? Can you guess?
Hx of immunosup (corticosteroids)
 Infection, osteoporosis

19. History
Recent procedure causing bacteremia
 Infection
 GU or GI procedures
Hx of IV drug abuse
 Infection
Bowel or bladder incontinence
 SCCS
Saddle numbness
 Cauda compression

20. Red Flags
Examination
General appearance
o lies still Vs writhes in pain
Vital signs
o BP : ↑,↓, R to L difference
o Fever
Pulsatile abdominal mass
Spinal process tenderness
Neurological deficits

21. Physical Exam Red Flags? What
do they mean?

22. Examination
Fever
 Infection BUT fever may not always be present
(especially vertebral osteomyelitis)
Hypotension
 Ruptured AAA
Extreme hypertension
 AD, especially if thoracic back pain
Pulsatile abdominal mass
 AAA

23. Examination
BP difference > 20 mm Hg in arms
 AD, but: BP difference > 20mm Hg in arms only
found in 40% of aortic dissections
- 20% of normals have this difference
Spinal process tenderness
 Fracture, osteomylelitis, SEA, malignancy
Focal neuro signs
 SCCS

24. Examination
Acute urinary incontinence
 SCCS / Cauda compression
 Actually is overflow incontinence
 Check for urinary residual > 150cc post void
Perianal numbness, loss of rectal tone
 SCCS / Cauda compression

25. Neurological Examination of the Back
Straight Leg Raise (SLR) Test
Motor
 L3-S1
Sensory
 L3-S1
 Rectal tone
 Perianal sensation
 Urinary retention

26. SLR

27. SLR
+ SLR ∼ 80% sensitive for herniated
disk at L4-L5/L5-S1 (95% of DH)
Leg passively elevated up to 7o°
+ test = new/worsening pain below
knee along path of a nerve root
between 30-70° of elevation
Reproduction of back pain or pain in
the hamstring is NOT a + test

28. + test can be verified by:
Ankle dorsiflexion
Internal rotation
Head flexion
Crossed SLR
SLR

30. Knee extension Foot inversionFoot inversion 1st
toe extension Foot eversion

31. A Word about S1
S1 radiculopathy cause weakness of plantar flexion,
but is difficult to detect until quite advanced
To illicit have the patient raise up on tip-toe three
times in a row, on one foot alone and then the other

33. Waddell Signs
≥3/5 signs more likely to have non-organic disease
 Excessive Tenderness
 Superficial: Widespread sensitivity to light touch of the
skin over a wide area of the lumbar skin
 Nonanatomic: felt over a wide area, not localized to one
structure, and often extends to the thoracic spine,
sacrum, or pelvis
 Stimulation
 Axial loading: ↑LBP with light pressure on skull while
standing
 Rotation: ↑LBP with passive rotation of shoulders and
pelvis in same plane, in standing position

34.  Distraction
 Inconsistent findings when patient is distracted, most
commonly seen when testing sitting versus supine SLR
 Regional Disturbance
 Motor: Generalized giving way or cogwheel resistance in
manual muscle
 Sensory: Glove or stocking, nondermatomal loss of sensation
 Overreaction
 Disproportionate verbalization or facial expression with
movement
 Assisted movement
 Rigid or slow movement
 Collapsing
Waddell Signs

35. Caution!
use in conjunction with entire presentation and not
as sole basis of discounting a patient’s symptoms
Waddell Signs

36. Diagnostic Studies
When is a diagnostic work-up required?
 When there are no red flags, a good history and physical
examination suffice
 When red flags are elucidated, further evaluation is
warranted

37. Laboratory Tests
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)

38. Plain Radiography
There is a sense among many patients that they should receive
x-rays as part of their evaluation!
Plain radiographs rarely add helpful information in
establishing the diagnosis
X-ray early in the course of LBP do not improve outcomes or
reduce costs of care
They add cost, time and unnecessary radiation
Normal plain films do not exclude malignancy or infection in
patients with a suspicious history

39. Radiation Risks
Gonadal radiation from a two view x-ray of the
lumbar spine = radiation exposure from a CXR taken
daily for > 1 year!!
Oblique views substantially increase risks of
radiation and add little diagnostic information

40. Indications for Back X-rays
Age ≤18 years or ≥50 years
Constitutional symptoms
Pain > 6 weeks
History of traumatic onset
History of malignancy
Osteoporosis
Infectious risk (e.g. IVDU,
immunosuppression, indwelling
urinary catheter, steroids, skin
infection or UTI, recent procedures)
Progressive focal neurologic deficit

41. MRI
Gold standard for evaluation for
 epidural compression
syndromes
 spinal infection (osteomyelitis
and epidural abscess)
 spinal cord injury
 intervertebral disk herniation
(may be delayed 4-6 weeks)
*MRI evaluation to provide reassurance does not
lead to better prognosis

42. Management
Nonspecific back pain (∅radiculopathy/∅ red flags)
 important to educate patients that they will
respond to conservative management over 4-6
weeks (many respond well after several days)
 Approach to treatment is focused:
 analgesic medications (combination therapy)
 activity modification
 physical modalities

43. Analgesics
Paracetamol
Excellent analgesic
Proven efficacy comparable to NSAIDs
inexpensive
Small side effect profile in comparison to
NSAIDs
Recommended in the treatment for all
patients

44. NSAIDs
Most are equally efficacious
Lowest dose needed to reach pain reduction should
be attempted
COX-2 inhibitors should be used sparingly and only
after discussion with the patient about the risks
Analgesics

45. The most common recommended approach is to use
a combination of Paracetamol and NSAIDs
One suggested regimen =
Paracetamol 500-1000 mg QID
+/-
Ibuprofen 400-800 mg TID
or Naproxen 250-500 mg BID
Analgesics

46. Analgesics
Opiates
Liberal use recommended for patients with
moderate-severe pain
Allows patients to break pain cycle
Gives stronger option when exacerbations of pain
occur
Only for short period (7-10 days) to ↓ development
of dependence
Warn patients of problems of driving

47. Muscle Relaxants
e.g. Diazepam
Cause sedation + addiction with chronic use
May be useful if patient demonstrates significant
muscle spasm of the paraspinal musculature
Exert benefit only in first 4 days when muscular
spasm is at its peak (rarely a significant component
of symptoms after 1st
week of injury)
Analgesics

48. Activity Modification/Physical Modalities
Continue routine activities as tolerated + use pain as guide for
activity modification
Bed rest has no benefit and may ultimately be harmful in the
recovery (not even 2 days!)
Active exercise/back strengthening exercises not beneficial
during acute crisis
Moderate stretching and strengthening of abdominal muscles
and back muscles beneficial when acute pain subsides
Thermal and ice therapy ?marginally effective

49. Other Modalities
None of the following treatments has shown
significant improvement in the recovery rate from
acute LBP:
 Traction
 Diathermy
 Cutaneous laser therapy
 Ultrasound
 Corsets & Lumbar braces
 Homeopathy
 Acupuncture
 Massage
 TENS

50. Management directed at restoring function and
supporting adaptive techniques:
Exercise
Reduction in body weight
Improving cardiovascular fitness
Smoking cessation
Massage- beneficial when combined with exercise
Acupuncture-may be beneficial
TENS-no benefit
Spinal manipulation-no benefit
Subacute/Chronic LBP

51. Subacute/Chronic LBP
Activity Modification

53. Medications
Paracetamol/NSAID
Avoid opiates & muscle relaxants
Antidepressants- cyclic
antidepressants
Subacute/Chronic LBP

54. LBP with Sciatica
1% -4% of individuals with LBP
Young = herniated disc, Older = spinal stenosis
Herniated disk
 50% recover in 6 weeks
 5-10% ultimately require surgery
 Surgery beneficial only in first 2 years
 No difference in symptoms at 4 and 10 years post
operatively

55. Management similar to patient with uncomplicated
LBP
Analgesics- Paracetamol, NSAIDs, short-term opiates
Activity- routine, use pain as limiting factor
Epidural steroid injection- mild-moderate pain
reduction
Must be diligent to detect progressive neurological
function
Patient should be educated to return earlier if the
symptoms are worsening
LBP with Sciatica

56. Indications for Referral
 Cauda equina syndrome – bowel and bladder dysfunction, saddle
anesthesia, bilateral leg weakness and numbness = surgical
emergency
 Suspected spinal cord compression – acute neurologic deficits in a
patient with cancer and risk of spinal metastases
 Progressive or severe neurologic deficit
 Neuromotor deficit that persists after 4-6 weeks of conservative
therapy
 Persistent sciatica, sensory deficit, or reflex loss after 4-6 weeks in a
patient with positive SLR , consistent clinical findings
 Fractures

57. Conclusions
Back pain is a costly and common problem
Evaluation done best by categorizing into 3 categories:
nonspecific back pain/back pain with radiculopathy/back
pain with specific cause
Systematic approach is key. Know your red flags well!
Remember radiation risk and x-ray only when indicated
Chronic back pain is complex and needs comprehensive
approach

59. Thank
You!