Common Back Pain

Acute/Chronic Nonspecific Low Back Pain

Pt with no h/o osteoporosis, osteoarthritis, malignancy presents with low back pain. Denies fever, weight loss, morning stiffness, gynecologic symptoms, urinary/GI problems. Negative straight leg raise on exam, 2+ reflexes and 5/5 LE strength b/l.

  • Initial management

    • Review/establish reasonable goals for pain control

    • Apply superficial heat

    • Obtain CMP prior to starting standing NSAID, Tylenol if concern for renal/hepatic dysfunction

      • Start naproxen 500 mg BID

      • Start Tylenol 500 mg 4 times daily PRN x 6 weeks

    • Consider cyclobenzaprine immediate release 5 mg TID x 2 weeks

    • Refer to physical therapy x 6 weeks (moderate quality evidence)

  • Follow-up at 6 weeks: If pt has not achieved reasonable pain control goals

    • Consider acupuncture (moderate quality evidence)

    • NSAIDs ineffective, consider alternative therapies for chronic back pain (low quality evidence):

      • Duloxetine 30 mg qd for 1 week then increase to 60 mg qd as tolerated

      • Tramadol ER 100 mg qd then increase daily dose by 100 mg per week to maximum of 300 mg qd

    • Consider lumbar spine radiography in 1-2 months and/or referral to orthopedics vs. pain management

  • Counseling

    • Pt advised to remain active and engage in low-impact exercise (moderate quality evidence)

    • Pt counseled about realistic expectations for pain relief

 

Lumbosacral Radiculopathy

Pt with no h/o recent trauma presents acute onset back pain. Describes sharp/shooting low back pain with unilateral lower extremity radiation in a dermatomal distribution. Denies red flag symptoms including fevers, chills, night sweats, unexplained weight loss, leg weakness, urinary retention, fecal incontinence. Denies h/o vertebral fracture, malignancy, HIV, IV drug abuse. Positive straight leg raise, no lower extremity strength/sensory deficits, and no hyperreflexia with patellar/achilles reflexes on exam.

  • Initial treatment

    • Obtain CMP prior to starting standing NSAID, Tylenol if concern for renal/hepatic dysfunction

      • Start naproxen 500 mg BID

      • Start Tylenol 500 mg 4 times daily PRN x 6 weeks

    • Refer to physical therapy

    • Pt instructed to call office if any red flag symptoms develop (see HPI)

  • Schedule follow-up visit at 6 weeks

    • If NSAIDs ineffective consider

      • Amitriptyline 50 mg qhs; titrate to 150 mg qhs as tolerated

      • Gabapentin immediate release 100 mg qhs; increase daily dose by 100 mg per week to 100 mg TID (maximum daily dose 1,200 mg TID)

    • Continued pain/radicular symptoms and/or new onset disability

      • Obtain MRI

      • Refer to orthopedics for epidural steroid injection

Notes

  • Most common etiologies include nerve root compression associated with

    • Disc herniation

    • Spondylosis (neural foraminal stenosis generally due to degenerative arthritis)

  • Nonskeletal etiologies include acute infection, vascular disease, and/or neoplasm

Emergent Back Pain Red Flags

Cauda equina

Pt with no significant PMH presents with back pain. Reports progressive motor/sensory deficit, bilateral sciatica, leg weakness, difficulty urinating, and fecal incontinence. Saddle anesthesia on exam.

  • Emergent MRI consistent with spinal cord compression

  • Concern for neoplastic epidural spinal cord compression

    • Refer for emergent surgery to be performed within 24 hours

    • Start dexamethasone

      • Day 1: 10 mg IV followed

      • Day 2 until surgery: Continue dexamethasone 8 mg PO BID

      • S/p surgery: Taper total dexamethasone dose by half every three days

Note: Urinary retention has 90% sensitivity for this condition; the probability of cauda equina in the absence of urinary retention is 1 in 10,000

 

Back pain with red flags for fracture:

Pt age >50 y/o with h/o osteoporosis, chronic oral steroid use, and IV drug use presents with chronic back pain. Reports recent trauma. Pain with palpation on exam.

  • Obtain CBC, ESR, CRP

  • Obtain plain radiography

  • Consider MRI if initial testing negative and pain persists

  • Pt advised to seek emergency treatment for new onset neurologic disability

 

Back pain with red flags for infection:

Pt with h/o immunosuppression, IV drug use, and recent UTI presents with back pain with no improvement s/p 6 weeks conservative therapy. Reports fever, chills, peri-spinal penetrating wound. Fever, pain with palpation of back on exam.

  • Obtain CBC, ESR, CRP

  • Obtain plain radiography

  • Consider referral for emergency treatment

 

Back pain with red flags for cancer:

Pt age >50 y/o with h/o cancer presents with chronic back pain with no improvement s/p six weeks conservative therapy. Reports unrelenting pain at night, progressive motor/sensory deficits, unexplained weight loss. Pain with palpation on exam.

  • Obtain CBC, ESR, CRP

  • Obtain plain radiography

  • Consider emergent MRI due to progressive motor/sensory deficits

  • Pt advised to seek emergency treatment for unexplained fever, new onset neurologic disability