Lower back pain

Cause	Patient	Onset	Radiation	Exam	Evaluation	Treatment
Fracture	Malignancy Osteoporosis	Acute-subacute	Rare	Localized pain	xray	Pain meds Refer/admit
Malignancy	Hx of cancer Age > 50 Pain > 1 mo Incr. severity	Subacute	Yes with epidural mets	+/- decr neuro	xray ESR MRI/CT-M	Steroids Admit
Infection	Immunocomp IVDA Children	Subacute	Yes with epidural abscess	+/- decr neuro Localized pain Fever in 50%	xray ESR MRI/CT-M	Abx Neurosx consult
Musc/skel	Adults	Acute-subacute	Yes if herniated disc	+/- decr neuro + SLR	Nothing xrays? CT/MRI?	Pain meds Modified activity Referral
Cauda Equ	Adults-elderly	Acute-subacute	Bilateral S/S Urine/fecal changes Decr rectal tone Saddle anesthesia		MRI/CT-M	Neurosx

==

Work-Up

0) Icon

1) X-rays* (if have red flag)

2) CBC/ESR/Chem 7/UA (if >50 yo)

3) Abd aorta US (if susp AAA >60 yo)

4) Pain treatment

*X-RAYS

Adults: AP & lateral of lumbar spine

Children: add oblique views (to evaluate for spondolithesis)

CT/MRI INDICATIONS

1) Suspect disc dis. w. severe motor impairment,

2) Suspect abcess or mets w/ neuro involv.

3) Cauda equina syndrome.

4) Elevated ESR

Red Flags

History

-Pain >4 weeks

-Age >50 or <18

-History of trauma

-Bilateral sciatica (or LBP w/ new sciatica)

-Neurologic complaints

-Bladder/bowel incontinence

-Night pain

-Unrelenting pain despite rest and analgesics

-Fevers/chills/nightsweats

-IVDA history

-Hx of cancer

-Prolonged steriod use

-Unexplained weight loss

Physical Exam

-Fever

-Point vertebral tenderness

-Neurologic deficits

-?Patient writhing in pain

DDX

AAA

Cauda equina sy

Epidural abcess/hematoma

Spinal fracture with cord/nerve impingement

Back pain with neurologic def

Intervetebral disk herniation

CA

Meningitis

Siatica

Spinal fracture

Spinal stenosis

Transverse myelitis

Vertebral osteo

Acute ligamentous injury

Acute muscle strain

Ankylosing spondylitis

Degeverative joint disease

Intervetebral disk disase

Pathologic fracture

Seropositive arthritis

Spondylolithesis

Cholecystitis

Esophageal dz

Pleural effusion

Pancreatic dis.

Perffed ulcer

Retrocecal appy

Large bowel obstr.

Renal dz

Pelvic dz

PID

Nephrolithiasis

PNA

PE

Pyelonephritis

Retroperitoneal hemorrhage/mass

Cord Compression

L4: pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk.

L5: pain side leg, wk dorsiflex, sens. loss lat lo leg & web big toe, reflex intact.

S1: pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.

-Straight leg raise most sens., crossed most specific.

-Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.

-Sciatica: impinged or irritated nerve. radicular distr., sharp, NO paresthesias/pain distal to knee/neuro impairment.

-Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief.

Treatment (Pain)

Mild to mod:

-NSAIDs

Mod to Severe

-non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN

-OPIOD (vicodin or percocet) & nonsteroidal for 2-3 dy, then NSAID alone.

-#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril)

-Bedrest 2-3 days

-Referral

See Also

Back Pain (Red Flags)

Source

1/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)

Cause	Patient	Onset	Radiation	Exam	Evaluation	Treatment
Fracture	Malignancy osteoporosis	Acute-subacute	Rare	Localized pain	xray	Pain meds Refer/admit
Malignancy	Hx of cancer Age > 50 Pain > 1 mo Incr. severity	Subacute	Yes w/ epirdural mets	+/- decr neuro	xray ESR MRI/CT-M	Steroids Admit
Infection	Immunocomp IVDA Children	Subacute	Yes w/ epidural abscess	+/- decr neuro Localized pain Fever in 50%	xray ESR MRI/CT-M	Abx NeuroSx consult
Musc/skel	Adults	Acute-subacute	Yes if herniated disc	+/- decr neuro +SLR	Nothing xrays? CT/MRI?	Pain meds Modified activity Referral
Cauda equina	Adults-elderly	Acute-subacute	N/A	Bilateral S/S Urine/fecal changes Decr rectal tone Saddle anesthesia	MRI/CT-M	NeuroSx

Osteoporosis

Acute-subacute Rare Localized pain xray Pain meds

Refer/admit

Malignancy Hx of cancer

Age > 50

Pain > 1 mo

Incr. severity

Subacute Yes with epidural mets +/- decr neuro xray

ESR

MRI/CT-M

Steroids

Admit

Infection Immunocomp

IVDA

Children

Subacute Yes with epidural abscess +/- decr neuro

Localized pain

Fever in 50%

xray

ESR

MRI/CT-M

Abx

Neurosx consult

Musc/skel Adults Acute-subacute

Yes if herniated disc +/- decr neuro

+ SLR

Nothing

xrays?

CT/MRI?

Pain meds

Modified activity

Referral

Cauda Equ Adults-elderly Acute-subacute Bilateral S/S

Urine/fecal changes

Decr rectal tone

Saddle anesthesia

MRI/CT-M Neurosx

Work-Up

0) Icon

1) X-rays* (if have red flag)

2) CBC/ESR/Chem 7/UA (if >50 yo)

3) Abd aorta US (if susp AAA >60 yo)

4) Pain treatment

• X-RAYS

Adults: AP & lateral of lumbar spine

Children: add oblique views (to evaluate for spondolithesis)

CT/MRI INDICATIONS

1) Suspect disc dis. w. severe motor impairment,

2) Suspect abcess or mets w/ neuro involv.

3) Cauda equina syndrome.

4) Elevated ESR

Red Flags

History

-Pain >4 weeks

-Age >50 or <18

-History of trauma

-Bilateral sciatica (or LBP w/ new sciatica)

-Neurologic complaints

-Bladder/bowel incontinence

-Night pain

-Unrelenting pain despite rest and analgesics

-Fevers/chills/nightsweats

-IVDA history

-Hx of cancer

-Prolonged steriod use

-Unexplained weight loss

Physical Exam

-Fever

-Point vertebral tenderness

-Neurologic deficits

-?Patient writhing in pain

DDX

AAA

Cauda equina sy

Epidural abcess/hematoma

Spinal fracture with cord/nerve impingement

Back pain with neurologic def

Intervetebral disk herniation

CA

Meningitis

Siatica

Spinal fracture

Spinal stenosis

Transverse myelitis

Vertebral osteo

Acute ligamentous injury

Acute muscle strain

Ankylosing spondylitis

Degeverative joint disease

Intervetebral disk disase

Pathologic fracture

Seropositive arthritis

Spondylolithesis

Cholecystitis

Esophageal dz

Pleural effusion

Pancreatic dis.

Perffed ulcer

Retrocecal appy

Large bowel obstr.

Renal dz

Pelvic dz

PID

Nephrolithiasis

PNA

PE

Pyelonephritis

Retroperitoneal hemorrhage/mass

Cord Compression

L4: pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk.

L5: pain side leg, wk dorsiflex, sens. loss lat lo leg & web big toe, reflex intact.

S1: pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.

-Straight leg raise most sens., crossed most specific.

-Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.

-Sciatica: impinged or irritated nerve. radicular distr., sharp, NO paresthesias/pain distal to knee/neuro impairment.

-Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief.

Treatment (Pain)

Mild to mod:

-NSAIDs

Mod to Severe

-non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN

-OPIOD (vicodin or percocet) & nonsteroidal for 2-3 dy, then NSAID alone.

-#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril)

-Bedrest 2-3 days

-Referral

See Also

Back Pain (Red Flags)

Source

1/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)