High Yield Topics

Back Pain

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Back Pain

Back Pain
Rohit Robert Dhir BA
Damien Doute MD
A. Jay Khanna MD
Basics
Description
  • Low back pain, the most common
    musculoskeletal condition, is responsible for the loss of 17 million
    work days per year in the United States and ~$60 billion of the annual
    U.S. health care budget (1).
  • 70–80% of adults experience severe back pain at some time during their lives (1,2).
  • Back pain, which affects the bones,
    joints, ligaments, and muscles of the back, is a symptom that occurs
    primarily in middle-aged adults, but it also may occur in children and
    adolescents.
  • Pathologic back pain can originate within
    the spine (spondylogenic or neurogenic) or outside the spine
    (viscerogenic, vascular, or psychogenic) (3).
  • The clinician must evaluate each patient carefully to determine the nature of the pain.
  • Synonyms: Backache; Low back pain
  • Classification is organized broadly into traumatic and atraumatic conditions.
Epidemiology
  • Age:
    • Adults: Common
    • Children: Uncommon:
      • Children and adolescents with scoliosis may have mild pain.
      • Severe back pain in children should alert the clinician to look for a potentially serious problem, such as a tumor or infection.
  • Gender: Back pain is more common in males
    than in females because of their higher rates of involvement with
    manual labor, motor vehicle injuries, and industrial accidents.
Incidence
The estimated incidence of low back pain is 15–20% in the United States (4).
Prevalence
  • The lifetime prevalence of low back pain ranges from 13.8–31% (2).
    • Low back pain usually appears in the 3rd decade of life, peaks between the ages of 35 and 55 years (1), and decreases thereafter (2).
    • After 6 months, 7% of patients still experience back pain symptoms, but this figure drops to 2% after 1 year (5).
Risk Factors
  • Obesity
  • Smoking
  • Manual labor
  • Accidents
Genetics
No genetic predispositions are known.
Pathophysiology
No pathologic findings are applicable.
Etiology
  • Traumatic:
    • Fractures/microfractures (causes severe immediate back pain) (6)
    • Dislocations
    • Herniated discs
    • Ligament tears
  • Atraumatic:
    • Degenerative disc disease
    • Degenerative spinal stenosis
    • Inflammatory arthritis
    • Osteoporosis
    • Spondylolysis and spondylolisthesis
    • Neoplasms
    • Primary or metastatic tumor
    • Infection
Associated Conditions
  • AS
  • Rheumatoid arthritis
  • Sciatica with low back pain
  • Cauda equina syndrome
Diagnosis
Signs and Symptoms
  • Symptoms:
    • Low back discomfort/pain
    • Stiffness
    • Numbness
  • Signs:
    • Paravertebral muscle spasm
    • Motor weakness
    • Loss of deep tendon reflexes
    • Loss of sensation
    • Clonus
    • Positive Babinski sign
History
  • Because diagnostic and radiographic studies generally are ineffective, it is essential to obtain a thorough history.
  • It is important for the physician to use
    an objective, history-taking approach to eliminate the subjectivity of
    the pain experienced by the patient (2).
    • This procedure includes having the patient map out the area of pain instead of merely describing its location (7).
Physical Exam
  • Begin with a general inspection of the spine.
  • Note any asymmetry of the ribs, flank, or pelvis, and inspect the natural sagittal curvatures of the patient.
  • Assess ROM and determine local tenderness.
  • Note flexion, extension, lateral bending, and rotation of the lumbosacral spine.
  • Sudden pain accompanying movement is suggestive of a mechanical abnormality (7).
    • Pain with extension is common in patients with facet joint arthritis and spinal stenosis (5).
  • Elicit paravertebral muscle spasms and percussion tenderness.
  • The neurologic examination is crucial, and the following should be evaluated:
    • Motor testing
    • Strength testing
    • Deep tendon reflexes
    • Sensation
    • Gait examination
Tests
Lab
  • No specific laboratory tests
  • If one suspects infection, a complete blood count and ESR should be performed.
    • The ESR is more useful, however, and is consistently higher in infection.
  • These determinations also are useful in patients >50 years old as a screening test for multiple myeloma.
  • In young patients with substantial stiffness, a serum HLA-B27 test can be used to assess for AS.
Imaging
  • Imaging techniques rarely are relevant
    clinically unless they strongly correlate with the patient’s history
    and physical examination (8).
  • Conventional radiographs, CT scans, MRI,
    and technetium bone scans should be used only to confirm pathology or
    rule out a specific diagnosis (8).
    • Radiographs are not always necessary for
      patients with the 1st episode of back pain, especially if it is caused
      by minor trauma (such as lifting).
    • However, radiographs should be obtained
      if evidence from the history and physical suggest that a patient might
      have a substantial structural abnormality, such as AS (8,9).
    • CT and MRI scans (alone or in combination) are useful for detecting and localizing structural abnormalities precisely.
      • CT is useful for detecting bone abnormalities such as fractures or osteoid osteomas.
      • MRI is useful for detecting marrow abnormalities or soft-tissue processes such as metastatic bone disease.
    • Technetium bone scans are useful for detecting early bone infections and localizing metastatic bone lesions.

P.35


Differential Diagnosis
  • The differential diagnosis is extensive
    and can be broadly outlined based on the age of the patient and whether
    a traumatic event occurred.
  • Adults:
    • Traumatic:
      • Herniated discs
      • Compression fractures
      • Fracture/dislocation
      • Spondylolysis (traumatic)
    • Atraumatic:
      • Degenerative disc disease
      • Spinal stenosis
      • Inflammatory arthritis: Rheumatoid arthritis, AS
      • Spondylolysis and spondylolisthesis
      • Ligament strains
      • Neoplasms: Metastatic bone disease, multiple myeloma
  • Children:
    • Traumatic:
      • Herniated disc
      • Fracture
    • Atraumatic:
      • Scoliosis
      • Disc space infection
      • Vertebral osteomyelitis
      • Neoplasms
Treatment
General Measures
  • Most patients with low back pain can be
    treated nonoperatively with short-term bed rest in the supine position,
    NSAIDs, and physical therapy to improve muscle strength of the lower
    back.
  • Surgical treatment is rare: Only 1–2% of back pain sufferers are candidates (2).
  • Prolonged bed rest is not beneficial; the patient may have 2–3 days of bed rest after the incident of back pain (5,10).
  • During the initial period of severe spasm and pain (usually 2–7 days), patients may have restricted mobility.
  • If plain radiographs are normal, patients should be mobilized progressively with physical therapy and aerobic conditioning.
Special Therapy
Physical Therapy
  • Physical therapy, aimed at increasing endurance and strength, lowers the recurrence rate and shortens the history of back pain (5).
  • Effective low back exercises include the Williams flexion program and the McKenzie hyperextension program (10).
  • Patients are educated regarding activity modification and injury prevention.
  • Patients who are injured on the job often are referred for a work-hardening program.
  • Passive modalities of therapy, such as
    massage, acupuncture, and electrical stimulation, can provide immediate
    relief, but they do not help in long-term treatment (5,10).
Medication (Drugs)
  • NSAIDs are the medications of choice for decreasing inflammation.
    • Generally, they are prescribed for an initial 4–6 weeks.
    • If the pain resolves, the medication is discontinued.
  • Muscle relaxants do not have a major role, although they can be very helpful in patients with severe spasm and anxiety.
    • They are best used for short-term pain relief rather than for long-term use.
  • In the presence of an infection, intravenous antibiotics and rest are required to treat the infection and normalize ESR.
Surgery
  • The many operative procedures for back
    pain (the choice of modality depends on the nature of the individual’s
    problem) have several principles in common:
    • Decompression of any nerve root or spinal cord compression
    • Fusion to achieve a stable spine
    • Consideration of realignment and fusion to correct spinal deformities (i.e., scoliosis and spondylolisthesis)
  • Instrumentation is important to achieve
    fusion in a reliable manner, and multiple systems, including pedicle
    screws, interbody devices, and rods, are available.
  • More recently, lumbar disc arthroplasty
    has been suggested as a surgical method for treating discogenic low
    back pain that is refractory to nonoperative management.
    • Some controversy exists within the spine
      community as to whether this modality will become a widely accepted
      procedure for the treatment of discogenic low back pain.
Follow-up
Prognosis
  • The prognosis is good (not always excellent) in patients who do not have major structural abnormalities.
  • Patients with major fusions can return to
    most activities, but they generally do not tolerate heavy work or
    repetitive loading of the back.
Complications
  • Most complications stem from iatrogenic surgical failure (11) and include infection, neurologic trauma, pseudarthrosis (nonunion), loss of fixation, and chronic unexplained pain.
  • Cauda equina syndrome is a devastating complication that occurs when a lesion causes nerve root compression of the cauda equina.
    • Unchecked compression results in
      permanent neurologic loss, leading to paralysis of the lower
      extremities and loss of bladder and bowel function.
Patient Monitoring
  • Patients are followed at 4–6-week intervals until the pain subsides.
  • With rest, activity modification, and NSAIDs, patients should show progressive improvement.
    • If not, suspect a structural problem.
References
1. McCulloch J, Transfeldt E. Epidemiology and natural history of spondylogenic backache. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:240–246.
2. Kahanovitz N. Epidemiology. In: Diagnosis and Treatment of Low Back Pain. New York: Raven Press, 1991:1–3.
3. McCulloch J, Transfeldt E. Classification of low back pain. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:86–89.
4. Borenstein DG, Wiesel SW, Boden SD. Epidemiology of low back pain and sciatica. In: Low Back Pain: Medical Diagnosis and Comprehensive Management, 2nd ed. Philadelphia: W. B. Saunders, 1995:22–27.
5. Kahanovitz N. Idiopathic low back pain. In: Diagnosis and Treatment of Low Back Pain. New York: Raven Press, 1991:67–75.
6. McCulloch J, Transfeldt E. Spondylogenic back pain: osseous lesions. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:90–148.
7. McCulloch J, Transfeldt E. The history. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:247–256.
8. Kahanovitz
N. Radiographic and laboratory tests. In: Diagnosis and Treatment of
Low Back Pain. New York: Raven Press, 1991:43–66.
9. McCulloch J, Transfeldt E. The investigation. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:277–357.
10. McCulloch J, Transfeldt E. Treatment of lumbar disc disease. In: Macnab’s Backache, 3rd ed. Baltimore: Williams & Wilkins, 1997:393–413.
11. Kahanovitz
N. Postoperative complications and failed back. In: Diagnosis and
Treatment of Low Back Pain. New York: Raven Press, 1991: 121–126.
Miscellaneous
Codes
ICD9-CM
847.9 Back sprain
Patient Teaching
Education is important so that patients understand their condition and the various methods for preventing recurrent injuries.
Prevention
Prevention is best accomplished through the use of
specific back exercises, avoidance of exacerbating activities, and
implementation of aerobic conditioning.
FAQ
Q: Is lumbar spine surgery a 1st-line treatment for most patients with low back pain?
A:
No. Most low back pain resolves spontaneously or with nonoperative
management. Only a very small percentage of patients with persistent
discogenic back pain become candidates for surgical intervention.
Q: If infection is the suspected cause of an episode of back pain, which laboratory studies should be ordered?
A: Complete blood count, ESR, and C-reactive protein in addition to other laboratory studies, as indicated.

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