Low Back Pain and Lumbar Strains

Acute low back pain is pain of <3 mos' duration localized below the costal margin but above the inferior gluteal folds with or without leg pain.

Synonym(s): Lumbar strain; Lumbar sprain; Lumbago; Low back syndrome

Acute pain is felt in the low lumbar, lumbosacral, or sacroiliac region. It is often accompanied by sciatica, pain radiating down the distribution of the sciatic nerve.

Chronic low back pain is the same unremitting pain that has been present for more than 3 mos.

The total costs of low back pain in the U.S. exceed $100 billion per year from direct and indirect costs.

The most common musculoskeletal reason for office visits to primary care providers

Most common between the ages of 35 and 55

∼1% of the U.S. population is chronically disabled because of back problems, and another 1% is temporarily disabled.

Age

Activity

Occupation

Obesity

Smoking

Sedentary lifestyle

Psychosocial factors

Poor posture

Chronic flexion injuries

Exercise programs, posture training, body mechanics training, and weight loss have been advised.

U.S. Preventive Services Task Force has concluded that current evidence is not adequate to recommend for or against the routine use of interventions to prevent low back pain in adults.

Initial history should focus on the patient's age and pain characteristics (onset, duration, severity, quality, radiation, aggravating factors, alleviating factors).

Question patient about mechanism of injury and occupation.

Determine if serious underlying conditions (red flags) are responsible for the back pain: Fracture (steroid use, trauma, menopausal status); infection (fever, IV drug use, adenopathy, immunosuppression); cancer (weight loss, adenopathy, previous cancer); cauda equina syndrome (bowel or bladder incontinence, saddle anesthesia, major limb motor weakness).

Assess psychological and socioeconomic problems.

The patient should be assessed for the following red flags:

Pain located below the costal margin but above the inferior gluteal folds

Possible radiation of pain to buttocks and lower extremity

Pain aggravated by movement and alleviated by rest

Limited range of motion of back

Paraspinal muscular spasm is common.

Assess severity of pain by observing the patient's gait, posture, and demeanor.

Prior to examining the back, check the temperature, weight, skin, abdomen, pelvis, groin, peripheral pulses, and lymph nodes for pathology that may mimic spinal disease. A rectal exam should be performed to assess sphincter tone.

With the patient standing, assess stance, spinal curvature, range of motion, heel-walk, toe-walk, and squat. Locate area of maximal pain.

With patient sitting, assess deep tendon reflexes of the knee and ankle.

With the patient supine, assess the straight-leg raise, ankle and great toe dorsiflexion, hip range of motion, sacroiliac joint stability, muscle strength testing, and sensory testing.

With the patient in the prone position, assess buttock symmetry and perform femoral stretch test.

Pain in low back is exacerbated by movement and is often accompanied by focal muscle spasm in the lumbar extensors.

Patients prefer to stand in a semiflexed position and move slowly rather than sit motionless on the exam table.

Walk on heels (L4–5), then toes (S1–2).

Back muscles uncoordinated or guarding (signs for spasm)

Ankle and knee reflexes (objective data without reliance upon patient's volition)

Straight-leg raising and crossed straight-leg raising (possible acute disc herniation)

Herniated disc

Musculoskeletal sprains and strains

Degenerative joint disease

Posterior facet syndrome

Spondylolisthesis

Spinal stenosis

Osteoporosis

Ankylosing spondylitis

Referred pain

Tumor

Infection

Fracture

Genitourinary

Gynecologic

Psychogenic

85% mechanical back pain (MBP)

5% symptomatic herniated disc

4% compression fracture

4% spondylolysis/spondylolisthesis

2% tumor, infection, rheumatologic disease, or referred pain

Early osteopathic or chiropractic referral is often beneficial.

Early orthopedic or physical therapy referral is rarely indicated.

Begin walking as soon as possible.

724.2 Lumbago

847.2 Lumbar sprain