Back Pain

Jason E. Liebowitz, MD and John A. Flynn, MD, MBA, MEd

Ambulatory Curriculum 2018

Objectives
Evaluation and management of the patient presenting with back pain:
1. To be familiar with the anatomy of the spine and related structures
2. To know the differential diagnosis of low back pain
3. To know the inflammatory causes of low back pain
4. To know the important components of the history when evaluating the patient with
back pain
5. To know the important components of the physical exam when evaluating the patient
with back pain
6. To be familiar with the role of imaging and other studies in the evaluation of the patient
with back pain
7. To be familiar with the role of physical activity, pharmacotherapy, and physical therapy
in the management of the patient with back pain

CASES
Section 1: Anatomy
Joe Flacco is a 38-year-old man complaining of back pain after tiling his kitchen floor. He notes
numbness in his anterior shin. Symptoms have been present for 6 days. On the first day of
symptoms, he went to a walk-in clinic, and a plain film of his spine was obtained, showing
spondylosis of his lumbosacral spine. Which one of the following statements is correct?

A. Spondylosis refers to anterior displacement of one vertebral body over an adjacent

vertebral body.
B. His patellar reflex is likely to be reduced.
C. He is likely to have difficulty walking on his toes.
D. The most common site of intervertebral disc herniation is at the L3-L4 intervertebral
disc.
Pop Up Answers
A. Incorrect. Spondylosis refers to degenerative changes of the spine, often manifesting as
reduced intervertebral disc height and the presence of bone spurs. Anterior
displacement of one vertebral body over its adjacent vertebra is known as
"spondylolisthesis."
B. Correct! He likely has L4 nerve root involvement based on his symptoms, and thus his
patellar reflex will be reduced.
C. Incorrect. Toe walking is affected when the S1 nerve root is compressed. Our patient is
likely to describe difficulty in rising from a squat.
D. Incorrect. 98% of all disc herniation occurs at the L4-5 and L5-S1 levels.

Summary answer
The correct answer is B: His patellar reflex is likely to be reduced.

Introduction
Back pain is common, and proper diagnosis and management is an essential skill of the internist.
In the outpatient setting, back pain ranks second after upper respiratory tract infections when it
comes to primary care physician office visits. Back pain occurs in up to eighty-percent of the
general population during their lifetime.2 The natural history of "discogenic," "mechanical" back
pain, is such that ninety percent of cases will improve within four to six weeks.3 This is also
referred to as back strain or sprain, implying that there is an underlying stretching or micro-
tearing of paravertebral muscles or ligaments. As we shall see, a prolonged episode of back pain
(i.e., lasting longer than 4-6 weeks) is one of the red flag markers for more serious causes of
back pain. This module focuses on the evaluation and management of patients presenting with
new-onset low back pain.

Estimates of direct health care expenditures among individuals with back pain in the United
States have reached over $100 billion. On average, individuals with back pain incurred health
care expenditures about 60% higher than individuals without back pain. Days of absence per
back pain patient per year averages around 9 days in the United States. Up to one quarter of all
industry insurance claims are related to occupational low back pain, and 2% of the US workforce
is compensated for back injuries each year.4
In order to properly evaluate the patient presenting with low back pain, it is important to be
familiar with the musculoskeletal and neurologic anatomy of the spine.

Anatomy of the Spine

The key musculoskeletal components of the spine are the intervertebral disc, composed of the
annulus fibrosus and the nucleus pulposus, and the vertebrae (Figure 1). Vertebrae are
composed of the vertebral body, the pedicles, transverse processes, articular processes (which
articulate to form the facet joints), laminae, and spinous processes. Stacked on top of each
other, these create the vertebral foramen. Each vertebra "relates" to the adjacent vertebra
through articular processes. The column of vertebral foraminae creates the tunnel through
which the spinal cord passes.

Figure 1: Vertebra and Intervertebral Disc

The intervertebral discs are situated between adjacent vertebral bodies (Figure 2), providing a
flexible cushion between each vertebra.

Figure 2: Vertebra and Superimposed Intervertebral Disc

This intervertebral disc can undergo degenerative changes, causing the annulus fibrosus to tear
or even rupture, allowing the nucleus pulposus to impinge on the vertebral foramen and the
spinal cord, or the exiting nerve roots (Figure 3).

Figure 3: Herniated Nucleus Pulposus (HNP)

Depending on the site of intervertebral disc bulging or rupture, a patient may experience
symptoms based on spinal cord impingement or nerve root impingement. Looking at Figure 4,
we see that nerve roots exit at the same level as the vertebral body, so that the L3 nerve root
exits at the level of the L3 vertebral body. We can also see that an intervertebral disc herniation
is going to affect the nerve root of the lower vertebral body (i.e., HNP of the L4-L5 intervertebral
disc is going to pinch the L5 nerve root, since the L4 nerve root will have exited the spinal
column above this level). An MRI of an L4-L5 HNP is provided in Figure 5.

Figure 4: HNP and Nerve Root Impingement

Figure 5: MRI of HNP

Figure 5: Lumbar spine MRI at L4-5 level demonstrating herniated nucleus pulposus with left
lateral disc protrusion (a) and midline extrusion (b) with compression of the lateral recess and
central canal narrowing.
Localizing the lesion in the patient with radicular complaints
Radicular complaints are seen in the majority of patients with herniated discs, and the absence
of radicular symptoms makes herniated disc disease an unlikely cause of low back pain.5 Spinal
stenosis, degenerative disease of the spine, malignancy, and infection may also present with
radicular symptoms similar to herniated disc disease. The level of involvement of the spine may
be discerned by historical and physical findings, recalling the regions of the body innervated by
each nerve root (Figure 6).

Figure 6: The Dermatome Map

Although sensory signs and symptoms are less useful than motor signs and symptoms for
localizing the level of nerve impingement, the history may begin the process of localizing the
level of nerve impingement based on our knowledge of the dermatome map and the location of
symptoms noted by the patient (Table 1). 6,7
Table 1: Lesion Location and Symptoms6

In addition, combining what we know about the dermatome map and reflexes, we can further
refine our estimate of the level of nerve root compression by evaluating the reflexes and motor
strength in the lower extremities (Table 2). Ninety-eight percent of all herniated discs in the
lumbosacral spine involve either L4-L5 or L5-S1.8

Table 2: Physical Findings and Lesion Localization

The role of the history and physical exam in determining the etiology is discussed later in this
module.

We finish this section with a brief review of the terminology often used to describe anatomic
changes of the spine (Table 3).
Table 3: Terminology of Radiographic Changes Associated with Back Pain

Objective 2: Differential Diagnosis

Raymond Lewis is a 63-year-old male with a history of hypertension, diabetes, high cholesterol,
tobacco use, and low back pain who presents for follow up of leg pain. He has been complaining
of a burning pain in his buttocks, upper thighs, and calves when walking, and because of his
multiple vascular risks, you arranged vascular studies of his lower extremities. Mr. Lewis returns
one week after having had these studies. Surprising to you and to Mr. Lewis, his peripheral
circulation was normal.
In reviewing this case with your faculty preceptor, she suggests the possibility of
"pseudoclaudication," and wonders if Mr. Lewis might have spinal stenosis.

Which ONE of the following statements about spinal stenosis and other etiologies of low back
pain is true?

A. The leg discomfort associated with spinal stenosis is commonly relieved with sitting or
leaning forward.
B. Spinal stenosis is the most common cause of low back pain in individuals over the age of
45.
 C. Herniated intervertebral disc is the most common cause of low back pain in individuals
between the ages of 30 and 80.
D. Cancers that commonly metastasize to the spine include breast cancer, lung cancer, and
colon cancer.

Pop Up Answers
A. Correct! Pseudoclaudication, associated with spinal stenosis, should improve
immediately with sitting or leaning forward. Leaning back (extending the spine)
commonly worsens symptoms.
B. Incorrect. Spinal stenosis probably causes about 3% of all cases of low back pain.
C. Incorrect. Lumbar strain is the most common cause of low back pain.
D. Incorrect. While breast and lung cancer may metastasize to bone, colon cancer does not
commonly metastasize to bone. Prostate cancer and myeloma are other cancers that
commonly metastasize to bone.

Summary answer
The correct answer is A: The leg discomfort associated with spinal stenosis is commonly
relieved with sitting or leaning forward.

Having reviewed the anatomy of the spine, we turn to the differential diagnosis of back pain.

Differential Diagnosis
The differential diagnosis of back pain is broad, and includes benign conditions that resolve with
little intervention, and serious disorders that may require urgent evaluation and treatment. Not
all back pain is related to the spine and related muscles and bones; abdominal pathology may
present with a chief complaint of back pain.

The different etiologies of low back pain can be categorized in many different ways.
Anatomically, back pain can be differentiated into:

Etiologies related to pathology of the musculoskeletal components of the back

Etiologies related to abdominal/pelvic pathology
Etiologies related to musculoskeletal components of the back
The majority (i.e., 98%) of patients presenting with low back pain will have an etiology arising
from pathology of the musculoskeletal components of the back9 (Table 4).

Table 4: Common Causes of Back Pain

The most frequent etiology of back pain is idiopathic, and is commonly termed "back strain" or
"lumbar strain." While the pathogenic mechanism of lumbar strain leading to the sensation of
pain is poorly understood, it is felt to arise from abnormalities of the facet joints of vertebral
bodies, intervertebral discs, and adjacent soft tissues and ligaments. These cases are frequently
associated with overuse and lack any specific neurological deficits, although patients may
complain of pain radiating to their buttocks.10 The patient may complain of difficulty standing
upright, or finding a comfortable position.
Following lumbar strain, the second most common cause of musculoskeletal back pain is
degenerative changes of the lumbosacral spine. More commonly seen in the elderly, the clinical
spectrum of symptoms can range from a mild ache in the lumbosacral spine to incapacitating
sciatica or pseudoclaudication. In these patients, sciatica results from nerve root compression as
osteophytes or other degenerative changes impinge on the nerve root.11 Spinal stenosis results
when hypertrophic and degenerative changes (e.g., spondylosis) progressively narrow the spinal
canal (Figure 7).

Figure 7: Lumbar spine MRI demonstrating spinal stenosis. T2-weighted sagittal view
demonstrates multilevel narrowing of the lumbar spinal canal due to osteoarthritis.

The classic symptom of patients with spinal stenosis is "pseudoclaudication." With

pseudoclaudication, the patient describes pain in the calves (often with discomfort in the
buttocks or upper thighs) with walking, which is also worsened by standing upright or extending
the spine. Flexing the spine (as in leaning forward) may improve symptoms (Figure 8). Therefore,
patients with spinal stenosis may describe worsening of symptoms when walking downhill that
improves walking uphill or improves when sitting or pushing an object such as a shopping cart.
In addition to pseudoclaudication, patients with spinal stenosis often describe pain and
weakness in the legs. Gait is often broad based, as proprioception fibers in the dorsal columns
are affected.10

Figure 8: Lumbar spine myelograms demonstrating spinal stenosis. In the image on the left, the
spine is extended (as when standing upright), with occlusion of the canal at the L4-5 interspace.
In the image on the right, the spine is flexed, as when bending forward, opening the canal to
allow passage of dye.

Another cause of acute musculoskeletal back pain that is more commonly seen in the elderly
(especially women) is the vertebral compression fracture of osteoporosis. Severe, non-radiating
back pain is the common symptom, which may be initiated by lifting an object. Similar in
frequency to vertebral compression fractures is herniation of an intervertebral disc.9 Often (but
not always) accompanied by a history of twisting or lifting, disc herniation is usually seen in
patients of middle age and older. Age-related degeneration of the annulus fibrosus or posterior
longitudinal ligaments puts the individual at risk for herniation with even low levels of load
bearing (such as a sneeze). Radicular symptoms and an abnormal neurologic exam are common
in patients presenting with herniated discs.

Although rare (total 1% of cases of back pain), ominous musculoskeletal causes of low back pain
include infection or malignancy of the spine or related structures. Osteomyelitis of vertebral
bodies (usually due to S. aureus, but includes S. epidermidis and M. tuberculosis), discitis
(infection of the intervertebral discs), and epidural and paraspinal abscesses may present as
back pain. Intravenous drug use, recent spinal surgery or procedures, and high risk tuberculosis
exposure are all infectious risk factors. Malignant involvement of the spine is usually metastatic,
and may reflect prostate cancer, renal cell carcinoma, breast cancer, lung cancer, myeloma or
lymphoma. Primary tumors of the vertebral bodies or spinal cord are rare. Spinal epidural
hematoma is a rare condition causing spinal cord compression. Hematomas are commonly
associated with epidural anesthesia, lumbar puncture, and myelography. Added risk factors
include coagulopathies, thrombocytopenia, blood dyscrasias, antiplatelet agents, and older age.

Finally, ankylosing spondylitis, inflammatory bowel disease-associated spondyloarthritis,

reactive arthritis, and psoriatic arthritis may all involve the lumbosacral spine, and are discussed
further below.9

Etiologies related to abdominal/pelvic pathology

Although rare (2% of all cases of back pain), patients presenting with low back pain may not
have a disorder related to the musculoskeletal structures of the spine (Table 5). For instance,
pyelonephritis commonly presents with low back pain (along with nausea, vomiting, fever, and
dysuria). Similarly, perinephric abscess and nephrolithiasis are other renal disorders that may
present as low back pain. The pain of pancreatitis classically refers to the mid-back, and a
posterior, penetrating duodenal ulcer similarly may present as back pain. Men with prostatitis
may present with back pain, and although most commonly associated with abdominal pain, an
aneurysm of the abdominal aorta may present with back pain. Women with pelvic inflammatory
disease or endometriosis may complain of back pain.

Table 5: Abdominal and Pelvic Causes of Back Pain

Objective 3: Inflammatory etiologies of low back pain
Jacoby Jones is a 35-year-old male who presents for evaluation of low back pain. He has been
complaining of an aching low back pain that is worse in the morning, and improves by mid-day.
He also describes episodes of swelling of his right 3rd toe and left 4th digit. He denies noting any
rashes, ocular symptoms, or changes in bowel habits. On examination, you note pitting of his
fingernails, and residual swelling of the entire left 4th digit. On closer examination, you note
thickening, scaling, and redness of the skin around the umbilicus, which the patient had not
noted previously.
In reviewing this case with your faculty preceptor, he suggests the possibility of psoriatic
arthritis. Which ONE of the following statements about psoriatic arthritis and other
inflammatory etiologies of low back pain is TRUE?

A. The skin changes of psoriasis always precede musculoskeletal symptoms in patients with
psoriatic arthritis.
B. Back pain secondary to inflammatory causes improves with rest, and worsens with
activity.
C. Inflammatory eye disease can be associated with spondyloarthritis.
D. Spondyloarthritis associated with inflammatory bowel disease occurs more commonly in
women.

Pop Up Answers
A. Incorrect. Psoriasis can occur concurrently with musculoskeletal symptoms in 20% of
cases. In some cases, it can even present after the onset of musculoskeletal symptoms.
B. Incorrect. Back pain due to inflammatory causes improves with activity.
C. Correct! Inflammatory eye disease can be associated with any of the causes of
inflammatory back pain.
D. Incorrect. Spondyloarthritis associated with inflammatory bowel disease occurs more
commonly in men.
Summary answer
The correct answer is C: Inflammatory eye disease can be associated with spondyloarthritis.

Inflammatory etiologies of low back pain

Inflammatory causes of back pain are referred to as spondyloarthritis. The most classic form of
spondyloarthritis is ankylosing spondylitis. Other spondyloarthritides are psoriatic arthritis,
reactive arthritis (formerly known as Reiters syndrome), and the spondyloarthritis associated
with inflammatory bowel disease. Common features of these conditions are the insidious onset
of back pain and the presence of enthesitis. Enthesitis is the inflammation of ligament and
tendonous insertions into bone. Examples of enthesitis include Achilles tendinitis and plantar
fasciitis, but inflammation may be seen at any insertion of ligament into bone.

In someone with spondyloarthritis, the symptom of back stiffness is the most common
presenting feature. Typically, the patient will complain of stiffness that is worse in the morning,
and improves as the day goes on. This is to be distinguished from degenerative arthritis as a
cause of low back pain, which worsens with physical activity.

Because of involvement of the sacroiliac joint in spondyloarthritis, the patient may also
complain of pain within the buttock; this can be unilateral, alternating, and eventually bilateral
unless treatment is initiated. Involvement of the sacroiliac joint is shown in the x-ray below.

A B

Figure 10: Plain radiograph of the sacroiliac joints. A shows normal SI joints (yellow arrows). B
shows SI joints in a patient with ankylosing spondylitis. Irregularity is demonstrated in this
image, along with sclerosis, creating an effect referred to as the "rosary-bead effect (black
arrow).

When inflammatory bowel disease-associated spondyloarthritis is suspected as a cause of back

pain, it is important to ask about abdominal cramping, bloody stools, diarrhea, and possibly
nausea and vomiting (i.e., symptoms suggesting Crohn disease or ulcerative colitis). A prodrome
involving a gastrointestinal or a urinary tract infection usually precedes reactive arthritis, and
the disease process carries a better prognosis than the other spondyloarthritides. Patients with
psoriasis can develop both peripheral and axial spondyloarthritis as part of their disease,
although axial involvement is less common than the more classic peripheral arthritis
presentation. Inflammatory eye disease (e.g., anterior uveitis) is also associated with
spondyloarthritis.

The most common causes of inflammatory spondyloarthritis are reviewed below:

Ankylosing spondylitis: presents as back pain and stiffness, worse in the morning,
improving with exercise. Men are affected more commonly than women. Age of onset
may be as a teenager, or up through the late 30s. Patients commonly describe buttock
pain that often starts unilaterally, may alternate from side to side, and eventually
becomes bilateral. Hip and shoulder joints may also be involved. This condition is
diagnosed based on the presence of inflammatory back pain, limitation of spinal range
of motion, and abnormal radiographs of the sacroiliac joints (see Table 6).36

Table 6: The Assessment of SpondyloArthritis International Society (ASAS) Criteria for

Classification of Axial Spondyloarthritis36
While previously considered a disease that insidiously progressed to eventual spinal fusion, the
current use of tumor necrosis factor inhibitors is being viewed as a major advance in the
treatment of this condition. Comprehensive guidelines are available from the American College
of Rheumatology.36

Figure 11: Progression of deformities seen in an individual with ankylosing spondylitis over a
time period of 26 years. Thoracic kyphosis develops, with loss of the normal lumbar lordosis.
Flexion contractures of the hips and knees then develop. In the final image, bilateral hip
replacements have resulted in improved posture.

Psoriatic arthritis: most commonly presents with peripheral arthritis that can involve
more distal joints in a symmetric or asymmetric pattern. It may also present with
involvement of the spine and sacroiliac joints, often with Achilles tendinitis and sausage
digits (of the upper extremities, but occasionally may involve the toes). By definition,
patients with psoriatic arthritis must have cutaneous involvement with psoriasis (Figure
12), and in most cases, the skin disease has been present for many years prior to
development of joint disease. However, in up to 20% of patients, these conditions may
co-occur and the patient may not be aware of the presence of psoriasis. In such a case,
it is essential to do a thorough skin examination, looking for the classic scaling rash of
psoriasis.

Figure 12: Psoriatic arthritis: nail changes, rash, and arthritis involving the hands. Note
characteristic erythema and swelling of the distal interphalangeal joints bilaterally. The left
fourth digit is diffusely swollen ("sausage digit"). Typical nail changes of psoriasis are noted,
while psoriatic skin changes are seen on the fourth digit and dorsum of the left hand.

Reactive arthritis (formerly Reiter's syndrome) may present with a constellation of

clinical symptoms including inflammatory spinal pain, enthesitis, a peripheral
oligoarthritis, as well as inflammation involving the eye (uveitis), and genital or
 cutaneous inflammatory lesions. In reactive arthritis, there should be evidence of
preceding infectious dysentery with diarrhea or genitourinary infection. The dysentery is
frequently associated with Yersinia, Campylobacter, Shigella, or Salmonella. With
genitourinary infection, the most common organism is Chlamydia.

Figure 13: Tendinitis of the heels, with swelling and erythema noted, especially on the left in this
patient with reactive arthritis.

Inflammatory bowel disease: Sacroiliitis and spondylitis can also occur in patients with
inflammatory bowel disease. This too occurs more commonly in men, with a classic
presentation of prolonged morning buttock stiffness and pain. Patients may also have a
peripheral oligoarthritis, with the knee being the most commonly involved joint. This is
a clinical diagnosis established in the proper setting with existence of inflammatory
bowel disease. In those patients who present with spondyloarthritis and oligoarticular
joint involvement, a careful history must be obtained to search for inflammatory bowel
disease.

Once suspected, these patients should be further evaluated for evidence of inflammatory spine
disease. This should include baseline labs evaluating for elevated acute phase reactants in the
form of sedimentation rate and C-reactive protein. These may be elevated in 40% of patients.
Physical examination should include a modified Schobers test (see Figure 14). Mark the
patients back at 5cm below and 10cm above the dimples of Venus. Then ask the patient to
bend forward with knees straight and measure the new distance between your two marks. This
distance should normally increase from 15cm to 20 cm or more. Another test is the occiput-to-
wall test (performed by having the patient stand with both heels and buttocks against a straight
wall. The neck is extended maximally in an attempt to touch the wall with the occiput and
having this distance measured). A distance of 0-2 cm is adequate to rule out cervical ankylosis
clinically. Full cervical flexion, extension and lateral rotation is also essential in ruling out cervical
ankylosis. Measurement of a change in chest wall expansion from maximal expiration to
maximal inspiration is also a useful test to ensure appropriate thoracic and costochondral joint
function.

Figure 14: How to Perform a Modified Schobers Test

Radiographic evaluation should include plain films of the sacroiliac joints evaluating for erosions
or fusion. If patients are suspected of having inflammatory back pain, they should be promptly
referred to a rheumatologist for further evaluation and management.

Objective 4: The History

Raymona Noodles is a 62-year-old with a history of hypothyroidism and asthma who presents
with a complaint of low back pain. She was in her usual state of health until one week ago, when
she developed the acute onset of what she described as 10/10 low back pain after lifting a bag
of groceries. The pain has responded only temporarily to ibuprofen 800mg. Pain is now
described as 8 out of 10, and does not radiate. She has no fever, no change in bowel or bladder
habits, and feels well otherwise. Medications include levothyroxine 125 mcg, prednisone 10 mg
(she's on a prednisone taper) and ibuprofen 800mg daily.

Which ONE of the following statements is correct?

A. Lumbar strain is the most likely explanation of this individual's low back pain.
B. The severity of back pain described suggests she has herniated an intervertebral disc.
C. Pain that is worse at night and pain that is worse lying flat are considered ominous
findings in the history of a patient with complaints of back pain.
D. If this patient had nerve root compression at the L4 nerve root, she would note pain
radiating to the plantar surface of her foot.
E. Cauda equina syndrome typically results in non-radiating low back pain and decreased
sensation in the perineum.

Pop Up Answers
A. Incorrect. Although lumbar strain is the most common cause of back pain, her age,
exposure to prednisone and history suggest a vertebral compression fracture.
B. Incorrect. The severity of back pain is not useful in determining its cause.
C. Correct. Night pain and pain that is worse lying flat should raise concern for malignancy
or infection.
D. Incorrect. The L4 nerve root supplies the anterior shin; radicular pain from the L4 nerve
root should radiate to the anterior shin.
E. Incorrect. Cauda equina syndrome most commonly results in sciatic symptoms
bilaterally, along with "saddle anesthesia" and changes in bowel or bladder habits.

Summary answer
The correct answer is C: Pain that is worse at night and pain that is worse lying flat are
considered ominous findings in the history of a patient with complaints of back pain.
While the majority of patients presenting with low back pain will have lumbar strain, more
serious causes must be excluded in every patient presenting with complaints related to the back
(often referred to as "red flags"). The exclusion of these serious causes begins with good history
taking.

Predisposing factors in the patient with low back pain

When first taking a history from a patient complaining of back pain, consideration is given to the
predisposing conditions that are associated with a higher prevalence of serious causes. For
instance, a patient with a history of corticosteroid use should be considered at risk for
osteoporosis, and therefore vertebral compression fractures. Metastatic disease and infection,
although rare causes of back pain, are the two most important areas of concern in an individual
presenting with back pain because delay of treatment may adversely affect outcome.

With regards to malignant disease presenting as back pain, since the risk of malignancy
increases with increasing age, many suggest that patients over the age of 50 should be
considered at increased risk for having metastatic disease involving the spine.12 Similarly, a prior
history of cancer (particularly those that spread to bone) should give the clinician pause before
diagnosing the patient with lumbar strain. Malignancies that often involve the spine include
prostate cancer (Figure 15), breast cancer, and multiple myeloma. Other malignancies that
metastasize to bone include thyroid cancer, lung cancer, and renal cell cancer. The symptoms of
cauda equina syndrome are discussed below.

Figure 15: Lumbar spine MRI demonstrating metastatic prostate carcinoma. Low-intensity
(black) areas in image on left are vertebral metastases. Lytic and sclerotic bony lesions are
visible in the plain film on the right.
Other than the risk factors for malignancy just mentioned, consideration should be given to
those who are at increased risk of having an infectious cause of low back pain. Because of the
recurrent episodes of bacteremia associated with injection drug use, a patient with a history of
recent injection drug use should be considered at risk for osteomyelitis, paraspinal abscesses,
and epidural abscesses. Similarly, a patient who has had a recent endovascular procedure
(including intravenous access) should be considered at risk for bacterial seeding of the spine and
related structures. Even a recent skin infection such as cellulitis should raise suspicion for spread
of infection to the spine.

As the differential diagnosis of back pain includes abdominal causes, a history of a recent urinary
tract infection should raise concern for pyelonephritis; a history of alcohol use should raise
concern for pancreatitis or perforating ulcer; a history of NSAID use should also raise concern for
ulcer; and an elderly patient with multiple vascular risk factors should raise concern for
abdominal aortic aneurysm (Table 7).

Table 7: Associated Features of Abdominal Causes of Back Pain

The role of subjective symptoms in the patient with back pain

In addition to the red flag predisposing conditions mentioned above, there are red flag
symptoms that are also of concern. Unexplained weight loss, especially in an elderly patient,
should heighten concern for malignancy. Nighttime pain, or pain that is worse lying down, also
raises concern for malignancy (or infection).9 Fever, although an insensitive marker, is felt to be
quite specific for osteomyelitis in patients presenting with low back pain.6 Pain lasting more
than a month, or that fails to respond to therapy, is also considered a red flag for a more serious
cause of low back pain.

A patient with inflammatory back disease, such as ankylosing spondylitis, generally has onset in
their second or third decade and will give a history of significant morning stiffness and
discomfort that is not relieved with lying flat.

A very ominous set of symptoms in the patient with low back pain is the cauda equina
syndrome. Cauda equina syndrome results from compression of the nerves of the cauda equina,
and often suggests malignancy or severe herniation of an intervertebral disc. Patients with
cauda equina syndrome may note decreased sensation of the perineum and buttocks ("saddle
anesthesia"), sciatic symptoms bilaterally associated with leg weakness, and bowel or bladder
dysfunction. Patients with these symptoms require emergent imaging and follow up.

Table 8: Review of Red Flag Signs/Symptoms

Section 5: The Physical Exam
John Harbaugh is a 54-year-old accountant with a history of benign prostatic hypertrophy who
presents with a chief complaint of low back pain. He was in his usual state of health until
yesterday, when he developed the acute onset of low back pain while playing golf. He denies
fever or chills, has no urinary complaints, and is taking only naproxen over the counter for pain
relief. On physical exam, he is afebrile, with normal vital signs. He has mild vertebral tenderness
in the lower lumbar spine. On neurologic testing, you note a decreased ankle reflex on the left.

Which ONE of the following statements about the physical exam is true?

A. Fever is a common finding in patients with herniated intervertebral discs.

B. Vertebral tenderness on physical exam is a highly specific marker for vertebral
osteomyelitis.
C. The straight leg raise test is performed with the patient supine, with the physician
attempting to raise the patient's leg while the patient resists.
D. His decreased ankle reflex suggests S1 nerve root compression.
E. L4 nerve root compression, which results from herniation of the L4-L5 disc, results in
gastrocnemius weakness.

Pop Up Answers
A. Incorrect. Fever is an ominous finding in the patient with acute low back pain, and
should raise suspicion for infectious etiologies, such as vertebral osteomyelitis or
paraspinal abscess.
B. Incorrect. Vertebral tenderness is a sensitive marker for vertebral osteomyelitis, as most
patients with vertebral osteomyelitis will have tenderness. However, many other causes
of low back pain may be associated with vertebral tenderness, making the finding non-
specific.
C. Incorrect. In the straight leg test, the patient should allow the physician to passively
elevate the leg. Reproduction of pain radiating below the knee is considered a positive
test.
 D. Correct. The S1 nerve root supplies the ankle reflex (and gastrocnemius).
E. Incorrect. The L4 nerve root is compressed by the L3-L4 intervertebral disc, and supplies
the patellar reflex and quadriceps.

Summary answer
The correct answer is D: S1 nerve root compression will manifest with a decreased ankle
reflex.

Once the history is obtained, attention is turned to the physical exam. The role of the physical
examination is to support your history and to evaluate for any neurologic deficits. A focused
physical exam may be useful in identifying the level of disc herniation in the patient presenting
with radicular symptoms. As with the history, the physical exam may reveal certain "red flag"
findings that will alter management of the patient presenting with back pain.

The straight leg raise test

An important question to be answered by the physical examination is whether or not there is
evidence of nerve root irritation, and for this we use the straight leg raise (SLR). The SLR is
performed with the patient in the recumbent position; the examiner slowly lifts the leg (the
knee remains extended) without assistance from the patient, creating traction on the sciatic
nerve. A positive test refers to reproduction of symptoms of sciatica at an angle less than 60
degrees, with pain radiating below the knee (not merely pain in the lower back or tightness of
the hamstring muscles).9,11 While the straight leg raise test is not specific (47-66%), it is rather
sensitive (56-71%) such that its absence makes nerve root compression less likely.13 The absence
of radicular symptoms and a negative SLR in a patient are a reassuring combination of findings in
the patient presenting with acute low back pain.

There are two ways to increase the specificity of the straight leg raise in a patient with a positive
SLR. In the first technique, the leg is raised just to the level that elicits radicular symptoms. The
leg is then lowered 5 degrees (pain should then resolve). If dorsiflexing the foot at this point
causes pain, the specificity of the positive straight leg raise for herniated disc is thought to be
increased.7 The second technique involves performing the straight leg raise on the contralateral
(unaffected) leg. If the contralateral (or "crossed") SLR reproduces sciatic symptoms in the
affected leg, that is a highly specific (85-94%), but not sensitive, marker for nerve root
impingement.13

Two examples of the SLR test can be found in video 1 and video 2.

Estimating the level of nerve root impingement

As we did in the beginning of the module, we review here the physical exam findings and the
correlate nerve root involvement in the patient presenting with back pain.

In the patient with radicular complaints or a positive SLR, the level of nerve root compression
can often be localized by examination of reflexes and motor strength in the lower extremities
(Table 9). Sensory findings have been found to be less useful.7

Table 9: Physical Findings and Lesion Localization

Figure 17: Lumbar spine MRI demonstrating HNP at L3-4 and L4-5 levels on this T2-weighted
image.

Other physical findings

While the physical examination in most patients with low back pain is normal, there are certain
findings that should heighten concern for a diagnosis other than lumbar strain. For instance,
fever is a very specific marker for osteomyelitis (or other infectious cause) for low back pain
(estimated specificity is 98%, but sensitivity is low).12 Vertebral tenderness on exam is sensitive
for infection, but not specific. An MRI of osteomyelitis is shown in Figure 15. Cauda equina
syndrome may demonstrate saddle anesthesia, a distended bladder, and decreased anal
sphincter tone. Spinal stenosis may be accompanied by decreased knee and ankle reflexes
bilaterally, and the patient may report increased pain when leaning backwards.
Figure 16: Lumbar spine MRI demonstrating osteomyelitis and disc space infection at the L2-3
interspace and L2 and L3 endplates (arrows). (Left image: non-contrast T1-weighted; center
image: non-contrast T2-weighted; right image: contrast-enhanced T1 weighted).
Consideration should also be given to abdominal pathology that may present with a chief
complaint of back pain; thus, the physical exam should include more than the musculoskeletal
and neurologic exam if any components of the presentation are atypical.

Section 6: Diagnostic Testing

Jamilla Jones is a 73-year-old woman who comes to clinic for evaluation of low back pain. She
contacted you over the phone earlier in the week to state that she had slipped on a wet floor
and awoke the following day with a pain in her back. Since then, Ms. Jones has gotten only mild
relief from acetaminophen, and she now comes in for evaluation. Her past medical history is
notable only for borderline elevation of her cholesterol.

On exam, the patient appears well. She is afebrile. Her heart and lung examinations are
unremarkable. She has point tenderness over the L4 region of her back, a negative straight leg
raise, and a normal neurologic examination.

Which ONE of the following statements about diagnostic testing is true?

A. Plain x-rays of the lumbar spine have no role in the evaluation of the patient with low
back pain.
B. A normal neurologic exam excludes the need for imaging in patients with complaints of
low back pain.
C. Herniation of an intervertebral disc is always symptomatic.
D. A plain x-ray of the patient's lumbar spine is appropriate.
E. An erythrocyte sedimentation rate should be sent to evaluate her back pain.

Pop Up Answers
A. Incorrect. Plain films of the lumbar are useful in patients with a history of trauma and
those in whom osteoporosis and vertebral compression fractures are suspected.
B. Incorrect. A febrile patient, or a patient with possible malignancy, should undergo
imaging of the spine even when the neurologic examination is normal.
C. Incorrect. Studies of MRIs done on asymptomatic individuals show herniated
intervertebral discs in about one-quarter of those imaged.
 D. Correct. Plain x-rays of the lumbar spine may be of use in evaluating patients with
trauma or suspected vertebral compression fractures.
E. Incorrect. The erythrocyte sedimentation rate may be of use in evaluating the patient
with back pain and suspicion for malignancy or infection.

Summary answer
The correct answer is D: A plain x-ray of the patient's lumbar spine is appropriate.

Diagnostic testing
Diagnostic testing to evaluate the patient with low back pain will be determined in large part by
the differential diagnosis after completing the appropriate history and physical. Since the
majority of patients presenting with acute low back pain will have a benign etiology, further
diagnostic testing, specifically imaging, is NOT indicated in most individuals. In their "Choosing
Wisely" campaign, the American Board of Internal Medicine (along with other organizations,
including the American Association of Family Physicians) identified imaging for the evaluation of
low back pain as a test that is overused, high cost, and often low value. They recommend the
following: "Don't do imaging for low back pain within the first six weeks, unless red flags are
present." Red flag symptoms include: severe or progressive neurologic deficits, fever, trauma,
history of malignancy, and sudden back pain with spinal tenderness in the setting of risk factors
for osteoporosis.14 For comprehensive clinical guidelines on appropriate diagnostic imaging for
low back pain, please see the guidelines from the American College of Physicians.15

Interestingly, there is a significant amount of evidence that radiographic findings frequently do

not correlate with symptoms, may contribute to a patient labeling phenomena, and do not
improve pain or quality of life. A study in the New England Journal of Medicine of MRI scans of
98 asymptomatic subjects (mean age 42.3 years old; range 20-80 years old) with no back pain
demonstrated that the majority (52%) had at least one bulging disc, and 27 percent had
protruding discs.16 These findings have been replicated elsewhere, and some spinal imaging
abnormalities in asymptomatic patients are so common that they might be thought of as
normal signs of aging .17-19 Additionally, some studies suggest that unnecessary imaging
contributes to a labeling phenomena whereby telling patients that they have abnormal spinal
imaging findings leads to a lower sense of well-being and hindered recovery15 Lastly, a meta-
analysis of six randomized trials (1804 patients with acute/subacute low back pain with no
features to suggest a specific underlying etiology) found no difference between diagnostic
imaging (plain film, MRI, or CT) versus usual care without imaging in terms of pain, function,
quality of life, or overall patient-rated improvement.20

Sometimes physicians may feel patients expect imaging for evaluation of their acute low back
pain. Careful conversation about the risks and benefits of these tests is important for high
value, cost effective care. Great resources for both patients and physicians in regards to these
conversations can be found on the Choosing Wisely website (see handout), and the AAFP
website (see video of an example discussion with a patient requesting imaging).

When to Order Diagnostic Imaging

Plain films may be of use when a fracture is suspected, including vertebral compression fracture.
Therefore, those patients with a history of trauma preceding the onset of back pain, or those in
whom the risk of osteoporosis is felt to be increased (e.g., elderly women; patients treated with
corticosteroids), should be evaluated with plain x-rays of the spine (anteroposterior and lateral
views). Outside of these patients, the role of plain films is quite limited.

The patient with radicular symptoms does not necessarily require evaluation with CT or MRI. As
mentioned, perhaps one third of individuals without low back pain will have evidence of a
bulging intervertebral disc. An otherwise healthy patient presenting with radicular complaints,
no red flags, and no evidence of major neurologic abnormalities does not need imaging unless
symptoms persist beyond 6 weeks. However, all patients with suspicion for infection,
malignancy, or cauda equina syndrome should be imaged emergently.

There is no evidence that one imaging modality (e.g., CT or MRI) is superior to another in
evaluating the patient with low back pain, but if bony abnormalities or fracture is the concern,
CT may be superior. Soft tissue evaluation, including paraspinous or epidural infections, may be
better seen with MRI. 8

Laboratory testing
Laboratory testing is of limited value in evaluating the patient with acute low back pain. Perhaps
the best studied is the role of the erythrocyte sedimentation rate (ESR) in a subset of patients
presenting with back pain. While of no use in the majority of patients with low back pain
because of its lack of specificity, the ESR may have a role in evaluating the patient in whom
cancer or infection (particularly osteomyelitis) is suspected. A very elevated ESR (>100mm/h) is
associated with an increased likelihood of infection or malignancy.8 Some suggest that
leukocytosis in the febrile patient with back pain is a specific marker for vertebral osteomyelitis,
but its sensitivity is too low to make this test useful.

A review of the steps in the initial evaluation of low back pain is shown in Figure 18.

Figure 18: Initial Evaluation of Low Back Pain

Section 7: Management of low back pain

Hallie Ngata is a 42-year-old woman with a recent history of herniated intervertebral disc (L4-
L5). This was diagnosed two weeks ago when she presented to an outside emergency
department with the acute onset of low back pain, and underwent MRI scanning that confirmed
the herniated disc. Mrs. Ngata was discharged with a prescription for acetaminophen/codeine
and cyclobenzaprine. She is now in your office, feeling somewhat better, but complaining of
fatigue and constipation. She asks for better control of her symptoms.

Which ONE of the following statements about treatment of low back pain is correct?

A. Epidural injection of cortisone should be administered, as it will reduce the likelihood of

her need for surgery.
B. One week of strict bed rest should be recommended to improve her symptoms.
C. Her narcotics and muscle relaxant should be discontinued and replaced with a non-
steroidal.
D. Physical therapy should be added to her current regimen.
E. The patient should undergo repeat imaging, as the duration of symptoms raises concern
that an infection or malignancy might have been missed.

Pop Up Answers
A. Incorrect. While these injections may bring acute relief, the long term need for surgery
is unaffected.
B. Incorrect. Patients told to advance their activities as tolerated recover more quickly than
those placed on bed rest.
C. Correct. NSAIDs are proven superior to placebo for management of acute low back pain.
The role of narcotics and muscle relaxers is less well established; they result in more
side effects, and should only be given for limited courses if needed.
D. Incorrect. It would be premature to initiate physical therapy without a trial of NSAIDs.
The impact of physical therapy on the management of low back pain is not well
established, especially in the acute setting.
E. Incorrect. It often takes 4-6 weeks for back pain to resolve. Her two-week course is not
of particular concern.

Summary answer
The correct answer is C: Her narcotics and muscle relaxant should be discontinued and
replaced with a non-steroidal.

While management of the patient with malignancy or infection as the cause of back pain
requires aggressive intervention (and is beyond the scope of this module), the vast majority of
patients will be sent home with recommendations as to how to relieve symptoms, and that is
the focus of this section.

Step 1: Patient Education

Patient education is an essential component for anyone who presents with acute low back pain.
Patients should be informed of the natural history of this condition in that there will likely be
improvement within several weeks' time. Patients should also be counseled that recurrence of
symptoms might occur in the future. Goals about pain management should be set.

As part of patient education, discussion should turn to the level of activity the patient should
assume. In the past, strict bed rest was a cornerstone of therapy, as it was felt to relieve
pressure on intervertebral discs and irritated structures. However, it has become increasingly
clear that resuming normal activity rather than bed rest results in more rapid relief of
symptoms. In one study, 186 patients were randomized to either bed rest for two days, back-
mobilizing exercises, or resumption of normal activities as tolerated.21 After 3 weeks and 3
months, the group assigned to resumption of normal activities had decreased symptoms as
compared to the other groups. Other studies have confirmed that limiting the amount of bed
rest and resuming normal activities as tolerated is associated with more rapid improvement of
symptoms. Patients should be advised to avoid prolonged sitting or standing, as well as bending
or lifting, until symptoms have dissipated.

Step 2: Pharmacotherapy
From a pharmacologic standpoint, non-steroidal anti-inflammatory drugs (NSAIDs) are effective
for short-term relief in patients with acute low back pain when compared to placebo.22 No
nonsteroidal is more effective than any other.22 Despite the efficacy of NSAIDs, acetaminophen
continues to be a potential therapy for mild to moderate back pain, especially in patients who
are intolerant to NSAIDs. However, even on this point, a recent set of guidelines for non-invasive
treatments for acute, subacute, and chronic back pain from the American College of Physicians
no longer recommends acetaminophen as pharmacologic therapy for back pain due to
insufficiency evidence of efficacy.37

With regards to the treatment of spondyloarthropathies, the treatment regimen requires a

multidisciplinary approach. Exercise is an integral part of any spondylitis management program
as regular exercise helps promote better posture and flexibility. NSAIDs remain the cornerstone
of treatment for pain and stiffness associated with spondylitis. As mentioned above, no NSAID
is superior to another. For patients with spondyloarthritis who have peripheral joint
involvement, disease modifying anti-rheumatic drugs (commonly called DMARDs) may be
considered. When NSAIDs are not enough, TNF-alpha blockers are very effective in treating
both the spinal and peripheral joint symptoms of spondyloarthritis. These treatment decisions
should be made by a specialist.

There is no evidence that muscle relaxants or narcotics are superior to NSAIDs for the acute
management of back pain, and the frequency of side effects is higher with these two classes of
medications. If used, narcotics and muscle relaxants should be given for a defined, short course
of treatment.13 No additional benefit has been found by adding muscle relaxants to
nonsteroidals over nonsteroidals alone.

Multiple studies have shown good evidence that systemic corticosteroids are ineffective for low
back pain or for sciatica, although they still get used for this purpose. One small randomized,
controlled trial did show a small improvement in pain relief and disability scores in those treated
with systemic steroids.23

Step 3: Physical Therapy

Physical therapy or spinal manipulation should be considered for patients who have not
responded to initial management. However, their role in the acute management of back pain is
uncertain. One study comparing physical therapy with spinal manipulation versus distribution of
a patient education booklet showed no real benefit of the physical therapy or spinal
manipulation. This has since been confirmed by an additional trial.24,25
If the patient is complaining of low back pain and states their symptoms are interfering with
home, work, or recreational activities, then consider referring your patient for physical therapy.
Physical therapists assess for posture dysfunction, faulty biomechanics, and for environmental
factors contributing to the development, persistence, or recurrence of low back pain. If on
exam, a patient has an obvious posture dysfunction, apparent leg length discrepancy, or gait
abnormality, then a physical therapy referral would be appropriate.

The goals of therapy are to restore normal posture, range of motion, muscle balance, core
strength and stability, gait and function, as well as to complete education on environmental
factors which could be modified to prevent recurrence. Physical therapy treatment consists of
addressing muscle imbalances through stretching exercises, soft tissue release, and manual
therapy techniques to correct alignment, spine stabilization exercises to maintain alignment as
well as instruction on a comprehensive home exercise program.

In the case of an acute disc herniation, acute medical pain management options should be
considered first, followed by a physical therapy referral once the pain has progressed to the
subacute stage.

Step 4: Complementary Therapy

Complementary therapy (e.g., acupuncture; chiropractics) has been shown to be more effective
in chronic rather than acute back pain, and has not yet had a major role in hospital-based
settings. A meta-analysis of 33 randomized controlled trials showed that true acupuncture is
significantly more effective than sham acupuncture alone for patients with chronic pain. The
data from this study were insufficient to recommend acupuncture for acute back pain.26 We
therefore do not recommend acupuncture except for complementary therapy from a licensed
acupuncturist, and only for chronic back pain. Randomized controlled studies have not found
back manipulation (i.e., chiropractic) to be better than other treatment modalities for acute
back pain.27

Step 5: Other Treatments

The evidence suggesting improved outcomes with other treatments, including epidural
corticosteroid injection or nerve stimulation, is minimal. Epidural corticosteroid injections may
increase short-term pain relief, but does not impact long-term outcomes or the need for
surgery.28 Nerve stimulation was found to offer no improvement in the management of back
pain.29

Most patients with low back pain do not require acute referral to a subspecialist, whether they
are a neurologist, neurosurgeon, or orthopedic surgeon. It is only in those patients with
progressive neurologic deficits and dysfunction, such as cauda equina syndrome, symptoms of
bowel or bladder dysfunction, or progressive lower extremity sensory or motor loss that require
such evaluation. Also, patients with intractable pain not controlled with conservative measures
should be considered for referral.

Considering surgery
The decision to treat low back pain surgically is a difficult one. Recent studies of selected clinical
scenarios may assist in this decision. One study was of patients with herniated vertebral discs
who were still symptomatic after 6-12 weeks of non-surgical treatment.30 In this study of 283
patients with severe sciatica, those randomized to early surgery (average time of 2.2 weeks)
reported more rapid relief of leg pain and perception of recovery compared to those patients
not randomized to early surgery. However, there was no significant difference in disability
scores in both groups at the end of the first year, and in both groups the probability of perceived
recovery at one-year was 95%. These results suggest that patients with acute herniation of
intervertebral discs will improve with or without surgery, but the patients undergoing surgery
get better more rapidly. Many of the patients (40%) who did not get surgery eventually
underwent surgery.

Another study looked at patients with more chronic back pain due to degenerative
spondylolisthesis and spinal stenosis.31 Patients in this study had radiographic evidence of spinal
stenosis, as well as symptoms of pseudoclaudication or radiculopathy, which had been present
for at least 3 months. Surgical treatment was lumbar laminectomy with or without spinal fusion
with bone grafting. Non-surgical treatment included physical therapy, education/counseling,
and NSAIDs. Although both groups improved, those undergoing surgery experienced greater
improvement in symptoms.
In an accompanying editorial, Richard Deyo (a nationally recognized expert in management of
back pain) states that these two studies show that surgery for back pain helps most with pain
management, but the decision to pursue surgery should be made through discussions between
the patient and his/her physician.32 He also reminds us that patients with major motor deficits
and major spine trauma definitely need surgery.

Finally, two recent studies on the role of vertebroplasty (which is injection of an acrylic
compound into a collapsed vertebral body) for osteoporotic spinal compression fractures
showed no benefit of this procedure in pain control and pain-related disability when compared
to controls.33,34

Figure 19 is a simplified version of the American College of Physicians and American Pain
Societys management algorithm of low back pain and summarizes strategies covered in this
module.35

Important Updates in Overall Management of Acute, Subacute, or Chronic Low Back Pain

In 2017, the American College of Physicians published a set of guidelines for non-invasive
treatments for acute, subacute, and chronic back pain. The main emphasis of these guidelines,
and an important change to recognize, is the emphasis on non-drug therapy for acute, subacute,
or chronic back pain before initiating drug therapy for these conditions. Potential barriers to
nondrug therapies may include insurance coverage issues, affordability, and availability. When
pharmacologic therapy is needed, the authors of these guidelines recommend NSAIDs or muscle
relaxants as first-line therapies and tramadol and duloxetine as second-line therapies. Only in
patients who fail non-drug, first-line pharmacologic, and second-line pharmacologic therapies
should opioids be considered, and even then a full discussion of the risks and benefits of opioids
should take place with patients.37

Figure 19: Review of Management of Low Back Pain

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