Back Pain

Christopher Wise, M.D., F.A.C.P. Medical College of Virginia at Virginia Commonwealth University

Definition/Key Clinical Features

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

Differential Diagnosis

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
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

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.
  - Cost/mo: $70 (50 mg)
Nonselective COX inhibitors: caution with renal disease, cardiovascular disease, edema, risk factors for peptic ulcer disease; moderate efficacy
- Ibuprofen
  - Cost/mo: $10 (800 mg)
- Naproxen
  - Dose: 500 mg b.i.d.
  - Cost/mo: $20
- Diclofenac
  - Dose: 75 mg b.i.d.
  - Cost/mo: $30
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.
  - Cost/mo: $150
Opiates: may cause constipation, sedation; potentially habit forming, use sparingly; most used in combination form with acetaminophen; moderate efficacy
- Propoxyphene
  - Dose: 100 mg q.i.d.
  - Cost/mo: $30
- Codeine
  - Dose: 30 mg q.i.d.
  - Cost/mo: $30
- Hydrocodone
  - Dose: 10 mg q.i.d.
  - Cost/mo: $60
- Oxycodone
  - Dose: 5 mg q.i.d.
  - Cost/mo: price not available

Muscle Relaxants Comparison

TCA Comparison