Back Pain

Christopher Wise, MD

Medical College of Virginia at Virginia Commonwealth University

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References


Definition/Key Clinical Features

• Usually aching pain in lower lumbar or sacroiliac area, worse with movement, relieved with rest and lying down

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Differential Diagnosis

• Lumbar spinal stenosis
• Neoplasm
• Infection
• Other lesions
  

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Best Tests

Acute Back Pain

• History and physical exam to identify risk factors [see Red Flags, below] and bony tenderness pain with straight-leg raising; assessment for loss of sensation or strength
• Further evaluation usually unnecessary in patients without red flags, because acute low back pain improves in 1 mo in > 90% of cases, and < 1% of patients will have serious underlying pathology that would be treated differently
• Reserve plain radiographs for high-risk patients

Persistent Back Pain

• Reassess if pain persists after 4-6 wk of conservative treatment
• Obtain plain radiographs and basic lab studies (CBC, ESR, chemistry profile, U/A) to screen for systemic illness
• MRI to confirm herniated disk or to evaluate for lumbar spinal stenosis, neoplasm, infection, other lesions
• Electromyography in selected patients; useful in differentiating lumbar radiculopathy from other causes of radicular leg pain
• Myelogram-CT scanning in selected patients to confirm lumbar stenosis

Test Comparison

• MRI: confirms herniated disk or other osseous or soft tissue lesions; many false positives in unselected patients with nonradicular pain
• Sensitivity: high for herniation and spinal stenosis
• Specificity: high false positive rate in asymptomatic patients (bulge in 20%-80%, herniation in 20%-40%, spinal stenosis in 20% older than 60 yr)
• Electromyography: useful in differentiating lumbar radiculopathy from other causes of radicular leg pain
• Sensitivity: uncertain
• Specificity: uncertain
• Myelogram-CT scanning: useful in selected cases of lumbar stenosis or other selected conditions, most useful in selected cases for planning surgery
• Sensitivity: similar to MRI
• Specificity: similar to MRI

Red Flags

• Indications that acute back pain may involve serious underlying conditions
• Patient demographics
• Age > 70 yr
• History of cancer
• Glucocorticoid therapy or immunosuppressive drug therapy
• Alcohol or I.V. drug use
• Historical features
• Weight loss
• Fever
• Pain increased by rest
• Neurologic symptoms
• Bowel or bladder dysfunction
• Saddle-block anesthesia
• Progressive motor weakness

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Best Therapy*

• Acute Back Pain

  • Avoid strict bed rest (at most 2-4 days)
  • Continue normal activities within limits permitted by pain
  • Mild analgesics and NSAIDs
  • Use muscle relaxants and opiates sparingly
  • Further studies (MRI, CT) indicated in patients with persistent sciatica or progressive pain
  • Surgery indicated in patients with radicular symptoms and clear-cut evidence of herniated disk correlating with symptoms

  Persistent Back Pain

  • Physical therapy with local modalities, exercise program, patient-education program emphasizing proper ergonomics for lifting and other activities
  • Encourage light normal activity and regular walking program
  • Use analgesics, NSAIDs, and TCAs judiciously
  • Consider further studies (MRI, CT) and consider surgical decompression by multilevel laminectomy and fusion for patients with herniated disk or spinal stenosis and progressive functional deterioration

  Analgesics and NSAIDs Comparison

  • Nonopiate analgesics: safest options; moderate efficacy
  • Acetaminophen
  • Dose: 650-1,000 mg t.i.d.-q.i.d.
  • Tramadol
  • Dose: 50–100 mg q.i.d.
  • Nonselective COX inhibitors: caution with renal disease, cardiovascular disease, edema, risk factors for peptic ulcer disease; moderate efficacy
  • Ibuprofen
  • Dose: 400-800 mg t.i.d.
  • Naproxen
  • Dose: 500 mg b.i.d.
  • Diclofenac
  • Dose: 75 mg b.i.d.
  • COX-2 specific inhibitor: safer than nonselective COX inhibitors regarding GI risk; used with caution with renal disease, cardiovascular disease, edema; moderate efficacy
  • Celecoxib (Celebrex)
  • Dose: 200 mg b.i.d.
  • Opiates: may cause constipation, sedation; potentially habit forming, use sparingly; most used in combination form with acetaminophen; moderate efficacy
  • Codeine
  • Dose: 30 mg q.i.d.
  • Hydrocodone
  • Dose: 10 mg q.i.d.
  • Oxycodone
  • Dose: 5 mg q.i.d.

  Muscle Relaxants Comparison

  • Muscle relaxants: may cause drowsiness, dizziness; use for limited time in most patients (1–2 wk); mild to moderate efficacy
  • Carisoprodol
  • Dose: 350 mg t.i.d.-q.i.d.
  • Cyclobenzaprine
  • Dose: 10 mg t.i.d.
  • Methocarbamol
  • Dose: 1,500 mg q.i.d.
  • Chlorzoxazone
  • Dose: 500 mg q.i.d.
  • Metaxalone
  • Dose: 800 mg q.i.d.
  • Tizanadine
  • Dose: 8 mg t.i.d.

  TCA Comparison

  • TCAs: More appropriate for chronic pain; caution regarding drowsiness, urinary retention, orthostatic hypotension, dry mouth; moderate efficacy
  • Amitriptyline
  • Dose: 10-100 mg q.h.s.
  • Nortriptyline
  • Dose: 10-100 mg q.h.s.
  • Desipramine
  • Dose: 10-100 mg q.h.s.
  • Doxepin
  • Dose: 10-100 mg q.h.s.
  • Imipramine
  • Dose: 10-100 mg q.h.s.
  
  

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Best References

Henschke N, Maher CG, Refshauge KM, et al: Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 60: 3072, 2009 [PMID 19790051]

Chou R, Qaseem A, Snow V, et al: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478, 2007 [PMID 17909209]

Chou R, Qaseem A, Owens A, et al: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med 154:181, 2011 [PMID 21282698]

Chou R, Huffman LH: Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 147:505, 2007 [PMID 17909211]

Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 147:492, 2007 [PMID 17909210]

Hayden JA, van Tulder MW, Tomlinson G: Systematic review: strategies for using exercise therapy to improve outcomes in low back pain. Ann Intern Med 142:776, 2005 [PMID 15867410]

May 2011