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Acute Back Pain

Christian Roehmer

Background

  • >90% of back pain is nonspecific and musculoskeletal in nature

  • Can’t Miss: Spinal cord compression, cauda equina, cancer, spinal abscess, discitis, or osteomyelitis

  • Extra-axial causes: Pancreatitis, nephrolithiasis, pyelonephritis, AAA, zoster

Presentation

  • Lumbar strain: diffuse pain in lumbar muscles, may radiate 

  • Degenerative disk or facet process: localized lumbar pain, similar to lumbar strain 

  • Inflammatory arthritis: morning stiffness, improves with movement, systemic symptoms 

  • Osteoarthritis: pain with use, improves with rest 

  • Herniated disk: radiating pain to legs, often below the knees 

  • Compression fracture: older patients, trauma, spine tenderness on exam 

  • Spinal stenosis: pain improves with flexion, shopping cart sign 

  • Spondylolysis: pain with extension 

  • Spondylolisthesis: pain with activity, improves with rest, can be seen with imaging 

  • Scoliosis: abnormal spine curvature, seen on physical exam inspection 

Evaluation

  • Physical Exam: 

    • Inspection: Should include posture, Adam’s Forward Bend Test (screens for scoliosis), and limb length discrepancy à kyphosis, lordosis, or scoliosis 

    • Palpation/Percussion: Sensitive for identifying spinal infection, metastases, or compression fractures

      • Spinous processes, lumbar “step-offs,” paravertebral muscles and SI joint

    • Range of Motion: Pain with extension and relieved by flexion suggests spinal stenosis  

    • Neurologic Examination:

      • L2: hip flexion; L3: knee extension; L4: dorsiflexion; L5: great toe flexion 

      • S1: plantarflexion 

    • Waddell’s Signs:  Raise suspicion of non-organic pain  

      • Superficial tenderness, pain that improves with distraction (attention diverted)

      • Pain with sham maneuvers (simulation)

      • Overreaction (disproportionate psychomotor responses)

      • Non-physiologic neurologic deficits

  • ESR/CRP: Can be used if concern for infection or malignancy

Provocation Tests of the Lower Back 
Test Isolates Action Positive if
Straight Leg Raise  Lumbosacral nerve roots  Pt is supine, lift one leg (keep straight) while the other leg is resting flat Positive for radiculopathy if pt experiences radiating pain to the leg being lifted 
Slump Test  Lumbosacral nerve roots  Pt is sitting, have them slump forward w/chin touching chest. Then passively extend knee and dorsiflex foot

Positive for radiculopathy 

if any of the steps reproduces radicular pain 
 Use with straight leg raise  
Gaenslen’s Test  Sacroiliac Joint  Pt supine, brings knee of leg of side not being tested to chest and holds it; examiner extends straight leg being tested over edge of bed  Reproduction of pain deep in upper buttocks 
Patrick’s (Fabers) Test  Sacroiliac Joint  Pt supine, passively flex hip to 90º, maximally abduct and externally rotate at hip  Reproduction of pain deep in upper buttocks 
Sacral Thrust  Sacroiliac Joint  Pt prone, apply anteriorly directed thrust over sacrum  Reproduction of pain deep in upper buttocks 
Distraction  Sacroiliac Joint  Pt supine, apply pressure directed postero-laterally to both anterior and superior iliac spine  Reproduction of pain deep in upper buttocks 
Compression  Sacroiliac Joint  Pt supine, apply pressure directed postero-laterally to both anterior and superior iliac spine  Reproduction of pain deep in upper buttocks 

Imaging: 

  • AP and lateral plain films; Bilateral oblique films (evaluate for spondylolysis)

    • Indications: risk of fracture, red flag symptoms, evaluating for ankylosing spondylitis, no improvement in pain after conservative therapy after 6-12 weeks

  • Non-contrasted MRI (Preferred)

    • Indications: Suspicion for spinal cord/cauda equina compression, severe neurological deficits, concern for infection, unexplained inflammatory marker elevation

Management

  • First line: conservative therapy for 4 to 6 weeks, avoid bedrest

    • PT

    • NSAIDs: Ibuprofen 600 – 800 mg q 4-6 hr, Diclofenac (topical) 2 g TID-QID (7 days)

    • Heat, massage, acupuncture

  • Adjuncts for pain:

    • Robaxin: 750 mg – 1.5 g 3-4 times daily for 2-3 days, then \< 4.5 g/day over 3-4 doses

    • Flexeril: 5 mg tid, or 5 once qhs with Tylenol or NSAID

  • Pts with neuro deficits or spinal cord compression warrant urgent surgical evaluation

  • Refer to Spine PT program at VUMC

  • Refractory or Severe Pain: Referral to orthopedics or PM&R spine specialist