low%20back%20pain
LOW BACK PAIN
It is pain, stiffness, or discomfort in the lower back area below the costal margin and above the gluteal creases.
Low back pain is also called spinal pain or lumbago.
Nonspecific low back pain is without identifiable specific causes and makes up 90-95% of all low back pain cases.  It also includes pain felt in the proximal lower extremities.
Patients with low back pain may have mobility deficits caused by severe or progressive neurologic disorders or comorbidities.
Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, or inflammatory disorders.
Low back pain associated with radiculopathy or spinal stenosis is dermatomal pain with or without neurologic deficits that is most often caused by nerve root compression.

Low%20back%20pain Diagnosis

Diagnosis

Red Flags

  • Take note of symptoms that may be secondary to underlying diseases
    • Incapacitating pain
    • Unrelenting night pain
  • Cancer
  • Infection (tuberculosis, pyogenic abscess)
  • Fracture
  • Cauda equina syndrome
    • Bowel/bladder dysfunction
    • Saddle anesthesia
    • Bilateral radiculopathy
  • Progressive motor weakness
  • Spondyloarthropathies 
    • Pain at night
    • Insidious onset
    • Improvement with movement

Yellow Flags

  • Psychosocial factors that may contribute to the chronicity of the disease
  • Mood changes
  • Level of job satisfaction
  • Attitude toward treatment participation
  • Attitude towards the disease
  • Involvement of loved ones with the management

Classification

Non-specific Low Back Pain

  • Low back pain without identifiable specific causes
  • Makes up 85-90% of all low back pain cases
  • Also includes pain felt in the proximal lower extremities

Specific Spinal Pathology

  • Patients with low back pain with associated mobility deficits caused by severe or progressive neurologic disorders or comorbidities
  • Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, inflammatory disorders

Low Back Pain Associated with Radiculopathy or Spinal Stenosis

  • Dermatomal pain with or without neurologic deficits
  • Most often caused by nerve root compression

Evaluation

Pain Intensity Level

Visual Analog Scale

  • A subjective examination that quantifies how patients rate the level of pain

Oswestry Disability Index (ODI)

  • A subjective tool used to evaluate a patient’s perceived functional disability
  • Score Perceived Disability Level
    0-20% Minimal disability
    21-40% Moderate disability
    41-60% Severe disability
    61-80% Crippled
    81-100% Bedridden

Roland-Morris Disability Questionnaire (RMDQ)

  • A disability measure to assess the subject’s disability caused by back pain
  • Patients with minimal disability perceive their pain as a disease that can be managed even without treatment
  • Patients with scores of 21-40% experience pain with regular movements (sitting, standing) and may complain of difficulty going to work
    • May demand conservative treatments
  • Patients with severely disabling pain are apprehensive to go about with their daily life if rigorous examinations and treatments are not provided
  • Patients with ODI scores of 61-80% are those whose everyday activities are greatly affected
    • Treatments and positive interventions are highly suggested

History

Pertinent Features

  • Location of pain
  • Duration of pain
  • Frequency of symptoms
  • Medical history (previous history of pain, treatment and treatment response)
  • Presence of weakness or neurologic deficits
  • Presence of red flags

Duration of Symptoms

Acute

  • Onset of symptoms <4 weeks

Subacute

  • Symptoms appeared 4-12 weeks prior to consult

Chronic

  • Onset of symptoms >12 weeks before consultation
  • Continuous or recurrent pain
    • Experience pain for at least half the days in the past 6 months

Physical Examination

Neurologic Exam

  • Examine muscle strength, deep tendon reflexes and sensation
  • Presence of muscle atrophy

Laboratory Tests

  • Complete blood count (CBC), erythrocyte sedimentation rate (ESR)
  • Used to rule out presence of tumor or infection

Imaging

  • Not recommended for patients with non-specific low back pain
  • Should be considered if red flags are suspected, surgery is being contemplated, and presentation is unconventional

Magnetic Resonance Imaging (MRI)

  • Imaging modality of choice
  • Should be considered for assessment of radicular symptoms, asymptomatic low back pain, chronic low back pain with red flags, subacute or chronic radicular pain with no improvement seen after 6 weeks of treatment
  • Indications:
    • Neurologic deficit (foot drop, hip flexion, knee extension)
    • Cauda equina syndrome
    • Persistent and progressive severe pain even with conservative treatments
    • Neoplasm is highly suspected
    • Spondyloarthropathy is suspected
    • Presence of infection highly likely
    • Trauma
    • Unresponsiveness to therapy and surgery is being considered

Computed Tomography (CT)

  • May be considered in patients with acute or subacute radicular pain unresponsive after 4-6 weeks of therapy, presence of red flags
  • CT myelography may be considered in patients with contraindications to MRI, if MRI is inconclusive, if with suspected bone neoplasms or with severe incapacitating back/leg pain

Radiography

  • Recommended for the evaluation of obvious deformities, acute low back pain with presence of red flags, and vertebral compression fracture
  • Anteroposterior (AP) and lateral views are indicated for acute low back pain that persists for >2 weeks without red flags
  • Flexion extension and oblique views are indicated when lumbosacral spine instability, spondylolysis or spondylolisthesis is suspected
  • Myelography may be considered if presentation of disease is uncommon

Radionuclide Scanning

  • May be used in patients suspected to have vertebral cancer

Nerve Conduction Studies

  • Successfully identify precise cause of nonradicular pain
  • May be considered for patients at high risk for extra-spinal pathologies

Electromyography (EMG)

  • May be considered for assessing acute low back symptoms and chronic non-specific low back pain
  • Needle EMG may be considered in patients with probable nerve root dysfunction of the lower extremities whose symptoms persist for >4 weeks

Spinal Diagnostic Interventional Techniques

  • Eg facet joint nerve block, sacroiliac joint injection, provocation discography
  • Consistent pain relief every time the affected nerve is anesthetized repeatedly may accurately identify the cause of low back pain

Invasive Diagnostic Procedure

Lumbar Provocation Discography

  • Identifies intervertebral disc pathologies causing low back pain
  • Indicated for patients with chronic low back pain with symptoms inconsistent with findings of MRI/CT scan 
  • Studies show that lumbar discography is more accurate than myelography
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