Back Pain

Christopher Wise, M.D., F.A.C.P.
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

• 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

• 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

• 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

• 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
    • Dose: 400–800 mg t.i.d.
    • 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