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Back Pain
Introduction
• Definitions
• History with red
flags
• Physical Examination
with red flags
• Diagnostic testing
• Treatment
• Sciatica and Back
Pain
• Epidural
Compression
Syndrome
• Vertebral
Osteomyelitis
• Back Pain in the
Cancer Patient
Definitions
• Low back pain: pain located between
the lower rib cage and the gluteal folds
– Extending or radiating into the thighs
• Acute: lasting less than six weeks
• Subacute: lasting between 6 and 12
weeks
• Chronic: lasting longer than 12 weeks
History Is Key!
Red Flags
• Less than 18 yrs of age
• More than 50 yrs of age
• Trauma (even minor if patient is elderly
or taking steroids chronically)
• Cancer
• Fever, chills, night sweats
• Weight loss
Red Flags
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Injection drug use
Compromised immunity
Recent GI or GU procedure
Pain at night
Pain radiating below knee
Pain with prolonged sitting, coughing,
or Valsalva manouver
Red Flags
• Severe and unremitting pain
• Incontinence, saddle anesthesia
• Severe or rapidly progressing neurologic
deficit
Age
• More than 50 years old or younger than
18
• Older than 50
– Tumor
– Abdominal aortic aneurysm
– Infection
Age
• Older than 65
– Hypertrophic degenerative spinal stenosis
• Under 18
– Congenital defect
– Tumor
– Infection
– Spondylolysis
– Spondylolisthesis
Duration of Pain
• Approximately 80% of patients with
acute low back pain will be symptomfree within six weeks
• Pain lasting longer: tumor, infection, or
a rheumatologic etiology
Location and Radiation of the Pain
• Muscular or ligamentous strain or disk
disease without nerve involvement
– Primarily in the back with radiation into the
buttocks or thighs
• Radiating below the knee, especially calf and
foot
– Nerve root inflammation below L3 level
• Approximately 95% of all herniated disks
occur at the level of either L4-L5 or L5-S1
Location and Radiation of the Pain
History of Trauma
• Major or minor trauma
– Elderly or chronic steroid user: Fracture!
• More likely to have osteoporosis
• Fall from a standing or a seated position
Systemic Complaints
• Constitutional symptoms
– Fever, night sweats, malaise, or
unintended weight loss
– Infection or malignancy
• More worrisome for infection if
additional risk factors
– Recent bacterial infection
– Immunocompromised status
Systemic Complaints
• Injection drug user: assumed to be
osteomyelitis or epidural abscess until
these conditions are ruled out by
diagnostic studies
• Recent invasive procedures, such as
colonoscopy
Atypical Pain
• Typical pain: dull, achy pain that is
exacerbated with movement and improves
with rest
• Tumor and infection
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Worse at night
Often awakens patient from sleep
Not relieved with rest
Unrelenting despite appropriate analgesic
treatment
Atypical Pain
• Worsened with prolonged sitting,
coughing, and the Valsalva maneuver:
Disk Herniation
Associated Neurological Symptoms
• Epidural compression syndrome (spinal
cord compression, cauda equina
syndrome, or conus medullaris
syndrome)
– Saddle anesthesia
– Bowel or bladder incontinence
– Erectile dysfunction
– Severe and progressive neurologic deficit
Associated Neurological Symptoms
• Residual bladder volumes
– Assist in the evaluation of bladder
incontinence
– Large post-void residual volumes:
significant neurologic compromise.
Evaluate for epidural compression
syndrome
Associated Neurological Symptoms
• Complaints of worsening paresthesias,
weakness, gait disturbances
– Single nerve root pathology: compression
by a herniated disk
– Multiple or bilateral nerve root complaints:
compression from a mass
History of Cancer
• Risk of metastatic spread to the spine
• Most likely to metastasize to the spine:
– Breast, lung, thyroid, kidney, prostate
cancer
• Primary tumors originating in the spine:
– osteosarcoma, lymphoma, multiple
myeloma, neurofibromas
Physical Examination is Vital!
Physical Examination
• Vital signs
– Fever: red flag for infection
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27% of patients with tuberculous osteomyelitis
50% of patients with pyogenic osteomyelitis
87% of patients with spinal epidural abscess
Absence of fever does not rule out spinal
infection
Physical Examination
• General appearance
– Benign low back pain: patients prefer to
remain still
– Writhing in pain or in extreme pain
• Spinal infection
• Abdominal aortic aneurysm
• Nephrolithiasis
Physical Examination
• Expose back and palpate
– History of trauma: focus on midline spinous
processes for tenderness
– Muscular spasm or edema
Physical Examination
• Lower extremity strength and sensation
– Focus on muscle groups and dermatomes
innervated by specific spinal nerve roots
– Patellar and Achilles reflexes: symmetry
– Babinski's test: upper motor nerve
syndrome
– All deficits or abnormalities should be
compared with the nerve root involved
Straight Leg Raising
• Evaluate for disk herniation
• Patient placed in the supine position. Leg
elevated by clinician up to 70 degrees
• Positive test: radicular pain below the knee
along the path of a nerve root in the 30- to
70- degree range of elevation
• Further verified by lowering the leg 10
degrees from the point of radicular pain and
dorsiflexing the foot
Straight Leg Raising
Straight Leg Raising
• Reproduction of back pain or pain in the
hamstring is not a positive test!
• 80% sensitive for disk herniation
• Positive crossed straight leg raise:
radicular pain down the affected leg
when the asymptomatic leg is raised
– Highly specific but not sensitive
Rectal Examination
• Integral part of examination of patients with
back pain
• Perianal sensation, rectal tone, and rectal
and prostatic masses
– Abnormal tone or sensation: bulbocavernous
reflex testing and anal wink
• Poor rectal tone in association with back pain
and saddle anesthesia: epidural compression
syndrome
Diagnostic Testing
Laboratory Tests
• Infection or tumor:
– CBC: elevated WBC count consistent with
infection
– ESR: elevated in infection and rheumatologic
disease. Also marker of an undiscovered
malignancy
– CRP: same as the ESR
– UA: UTI in patients who have evidence of spinal
infection. Urinary system common primary source
for such infections
Radiography
• Plain radiographs: simply not necessary in
the absence of red flags
• Concern for fracture, infection, rheumatologic
disease, or metastatic disease
– Anteroposterior and lateral films
• Magnetic resonance imagery (MRI) or
computed tomography (CT) if films negative
and concern remains
Radiography
• MRI
– Gold standard for compressive lesion of
the spinal cord or cauda equina, spinal
infection, or disk herniation.
– May be delayed for four to six weeks if disk
herniation is the only concern
Radiography
• CT
– Study of choice for bony structure
• Spinal trauma: spinal column stability and
integrity of spinal canal
• Vertebral osteomyelitis
– CT-myelogram in absence of MRI: epidural
compressive lesions
Treatment of Benign Acute Low
Back Pain
Activity
• No benefit of prolonged bed rest 1
• Recently shown that patients who resumed
their normal activities to whatever extent they
could tolerate recovered faster than those
who stayed in bed for two days
• Active exercise: not beneficial during acute
stage
• After recovery, exercise helps prevent future
episodes
1. How many days of bed rest for acute low back pain?
A randomized clinical trial. N Engl J Med 1986; 315:1064-70
Analgesia
• Mainstays of pharmacologic therapy:
acetaminophen, NSAIDs, and opiate
analgesics
• Acetaminophen: analgesic with proven
efficacy comparable to NSAIDs
– Inexpensive
– Innocuous side-effect profile
Analgesia
• NSAIDs: equally efficacious in the
management of acute pain
– Best to choose lowest effective dose based on
side effects and cost
• Opiate analgesics: moderate to severe pain
– Combinations of acetaminophen and codeine
phosphate, hydrocodone, or oxycodone
• Other medications
– muscle relaxants, such as diazepam,
methocarbamol, and cyclobenzaprine
Sciatica and Back Pain
Sciatica
• Sciatica: pain radiating along a nerve
root path to the foot
– Afflicts 2% to 3% of patients with low back
pain
• Compression of a nerve root by a
herniated nucleus pulposus
• Associated weakness, paresthesias,
and numbness along a nerve root
Sciatica
Sciatica
• More than 95% of disk herniations occur at
the L4-L5 or L5-S1 levels, corresponding to
L5 or S1 radiculopathies
• Other causes of nerve root irritation:
– Space-occupying lesions (including central canal
or foraminal stenosis, usually found in patients
over age 50)
– Tumor
– Hematoma
– Infection
Sciatica
Sciatica
• Outcome generally positive:
– 50% recovering in six weeks
– 5% to 10% ultimately require surgery
• Management similar to uncomplicated low
back pain
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Limited bed rest
Activity as tolerated
Analgesics
Steroids: epidural steroid injection produces mild
to moderate reduction in pain
Sciatica
• Radiographs not required
– Only to rule out bony pathology
– MRI: needed emergently only if patient has
a progressing neurologic deficit
Epidural Compression Syndrome
Epidural Compression Syndrome
• Encompasses:
– Spinal cord compression
– Cauda equina syndrome
– Conus medullaris syndrome
• Grouped together because:
– Similar presentation except for the level of
the neurologic deficit
– Similar evaluation and management until
actual diagnosis is known
Epidural Compression Syndrome
• Medical Emergency!
• Difficult to evaluate patients with early
signs and symptoms
– Broad initial differential diagnosis
– Determine whether symptoms are bilateral
– Evaluate combination of motor, sensory,
and autonomic dysfunction
Epidural Compression Syndrome
• Signs and symptoms:
– Minimal low back complaints
– Constipation or incontinence of the bowel
– Urinary retention or incontinence
– Saddle anesthesia
– Decreased rectal tone
Epidural Compression Syndrome
• Possible etiologies
– Large central disk herniation
– Spinal canal hematoma
– Spinal canal abscess
– Primary or metastatic tumor
– Traumatic compression
Epidural Compression Syndrome
• Emergent treatment with spinal cord
injury assumption:
– Dexamethasone 10 to 100 mg IV
administered immediately
• Emergent MRI
– Cervical, thoracic, and lumbosacral spine if
concern about possible metastatic
compression or infection
Epidural Compression Syndrome
• Outcomes dependent on presenting
neurologic deficits
– Paraplegic on presentation - unlikely to walk again
– Too weak to walk without assistance, but not
paraplegic - 50% chance of walking again
– Ambulatory at presentation - remained so
– Catheterized for a denervated bladder – most will
not recover bladder function
Vertebral Osteomyelitis
Vertebral Osteomyelitis
• Often missed on routine examination
• History very helpful in making diagnosis
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90% have back pain as primary symptom
Severe pain, commonly nocturnal and unremitting
Only 52% febrile at presentation
Only 10% appear septic or toxic
Injection drug use: assumed to be osteomyelitis or
epidural abscess until proven otherwise
– Recent UTI, pneumonia, GI or GU procedure
Vertebral Osteomyelitis
• Transplant patients and other
immunocompromised patients: increased risk
for septicemia and osteomyelitis
• Organisms:
– Staphylococcus aureus most common
– Escherichia coli, Proteus, and Pseudomonas
• Hematogenous spread with deposit in the
vertebral matrix around the sluggish venous
plexuses
Vertebral Osteomyelitis
• Evaluation
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WBC count may be elevated
ESR almost always elevated
Urinalysis
Blood cultures positive in more than 40%
Plain radiographs: may be normal
• Bony destruction, moth-eaten end plates, and narrowing
of disk spaces
– MRI: gold-standard
• Brightening of the marrow on T2, brightening of the disk
on T2, and darkening of the marrow on T1
Vertebral Osteomyelitis
Vertebral Osteomyelitis
• Cornerstone of treatment: IV antibiotics
– Six to eight weeks IV antistaphylococcal
– Followed by oral antibiotics for another four to
eight weeks
– Analgesics and bed rest
– Immobilization with an orthosis
– Surgery reserved for:
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Significant abscesses
Spinal cord compression
Significant bony destruction
Unresponsive to standard medical treatment
Back Pain in the Cancer Patient
The Cancer Patient
• Difficult to evaluate:
– Spinal metastases
– Devastating consequences if significant
lesion is missed
• Separate patients into three groups
based on symptoms
The Cancer Patient
• First group
– Signs and symptoms of progressive
epidural compression
– True medical emergency
– High-dose steroids and emergent MRI
The Cancer Patient
• Second group
– Mild, stable symptoms
– Isolated nerve root involvement
– Do not require high-dose steroids or
emergent MRI
The Cancer Patient
• Third group
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Majority of patients
Isolated pain with no neurologic deficits
Plain radiographs: MRI if metastases detected
Followed closely for two to three weeks
Remember:
• 50% bone destruction must occur before radiographs can
detect a lytic lesion
• 60% of patients with metastatic disease will have normal
radiographs
Summary
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History: Keep red flags in mind
Physical Exam: red flags again
SLR and Sciatica
Treatment for benign low back pain is
analgesics
• Epidural compression syndrome is a medical
emergency
• Appropriate imaging. Plain films usually not
needed
References
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www.emedicine.com
www.mdchoice.com
www.webmd.com
Emergency Medicine – Judith E.
Tintinalli. 6th Edition
• Rosen’s Emergency Medicine – 5th
Edition
Thank You!