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Updated: May 8 2021

Low Back Pain

  • Snapshot
    • A 46-year-old man presents to his primary care physician with lower back pain. His symptoms began approximately 3 weeks ago and has not subsided. The pain does not radiate, and he cannot recall what caused this. He endorses having night sweats and unexpected weight loss. He denies illicit drugs use and does not smoke. On physical exam, no saddle anesthesia, muscle weakness, or sensory changes are noted. An erythrocye sedimentation rate and prostate-specific antigen is elevated. Radiography of the lumbar spine demonstrates a compression fracture of the lumbar spine. (Metastatic prostate cancer leading to lower back pain)
  • Introduction
    • Definition
      • lower back pain
        • acute
          • 0-4 weeks
        • subacute
          • 4-12 weeks
        • chronic
          • ≥ 12 weeks
  • Epidemiology
    • Incidence
      • a very common primary care complaint
    • Risk factors
      • activity (e.g., heavy lifting)
      • sedentary lifestyle
      • psychosocial stressors (e.g., anxiety, depression, and stress)
      • increasing age
  • Etiology
    • Mechanical
      • degenerative disease
      • spondylolisthesis
      • herniated disc
      • spinal stenosis
      • spinal fractures
    • Nonmechanical
      • malignancy
        • multiple myeloma
        • spinal cord tumors
        • retroperitoneal tumors
      • infection
        • osteomyelitis
        • paraspinous or epidural abscess
          • associations: fever, back pain, elevated ESR/CRP, IV drug use, immunosuppression
        • discitis
          • focal back pain
          • MRI with edema seen at intervertebral discs
      • inflammatory arthritis
        • ankylosing spondylitis
        • reactive arthritis
        • inflammatory bowel disease
    • Differential
      • meralgia paresthetica (entrapment of the lateral femoral cutaneous nerve)
        • numbness, tingling, and pain of the anterolateral thigh
        • common in pregnancy
  • Presentation
    • Symptoms/physical exam
      • patients present with lower back pain; however, associated symptoms depend on the cause of back pain
        • e.g., disc herniation can lead to sensory changes in the affected dermatome
    • Red flag findings
      • bowel and bladder incontinence
      • saddle anesthesia
      • neurological findings
      • night sweats, fever, and weightloss
  • Imaging
    • Radiographs
      • indications
        • patients at risk for malignancy with an elevated erythrocyte sedimentation rate
        • patients at risk for vertebral compression
    • MRI
      • indication
        • in patients with neurological deficits
        • in patients with a fever, history of intravenous drug use, and immunosuppression
  • Studies
    • Erythrocyte sedimentate rate
      • in cases where there is suspicion for an inflammatory or infectious cause of back pain
  • Treatment
    • In the absence of 'red-flag' symptoms, treat conservatively
      • NSAIDs/acetaminophen and activity continuation
      • physical therapy
        • avoid bed-rest
    • Otherwise, treatment is dictated by cause of pain
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