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Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020
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Image courtesy of Wikimedia Commons | OpenStax College.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Back pain—in particular, low or lumbar back pain—is a cause of many visits to the emergency department (ED). From 70% to 85% of the population will suffer from back pain at some point in their lives. In fact, low back pain is the primary cause of disability in individuals younger than 50 years.[1] Determining the cause of back pain in a particular patient poses an interesting challenge to physicians, as the sources can include intervertebral disks, facet joints, vertebrae, neural structures, muscles, ligaments, and fascia.
Image courtesy of Medscape.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Shown are anteroposterior (left) and lateral (right) radiographs of a patient with ankylosing spondylitis.
Age is one of the more common risk factors for low back pain. According to some studies, incidence is highest in the third decade, and overall prevalence increases with age until age 60 or 65 years, after which it gradually declines.[2] Common problems include spinal stenosis (ie, narrowing of the central spinal canal or its lateral recesses, typically from hypertrophic degenerative changes in spinal structures[3]) and disk herniation. Inflammatory spondyloarthropathy (shown) is most common in men younger than 40 years, but clinical and demographic characteristics are of limited accuracy. Among patients older than 65 years, the diagnostic probabilities change. Cancer, compression fractures, spinal stenosis, and aortic aneurysms become more common.
Recovery from nonspecific low back pain is generally rapid. In one study, 90% of patients seen within 3 days of onset recovered within 2 weeks.[4] Recurrences are common, affecting 40% of patients within 6 months. Most recurrences are not disabling, but the emerging picture is that of a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured.
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
A 51-year-old woman with a pacemaker reports difficulty with urination and numbness in her buttocks bilaterally. The symptoms began 12 hours previously.
What is the most appropriate next step in management?
Magnetic resonance imaging (MRI) of the lumbar spine
Computed tomography (CT) myelography of the lumbar spine
Epidural steroid injection
Emergency lumbar decompression
High-dose methylprednisone
Image courtesy of NIH / Wikimedia Commons | Lesion.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Answer: B. Computed tomography (CT) myelography of the lumbar spine.
This patient has classic symptoms of cauda equina syndrome (CES). The most important next step is identifying a source of compression in the lumbar spine. The study of choice for this purpose is MRI (see images A-E in the slide); however, in patients who cannot undergo MRI (eg, those with pacemakers, such as the patient in this case), CT myelography should be performed.
CES has been described as a complex comprising low back pain, bilateral or unilateral sciatica, saddle anesthesia, and motor weakness that can progress to paraplegia and permanent bowel or bladder dysfunction. It constitutes an absolute indication for surgical treatment of lumbar disc disease. Historically, the recommendation was to proceed with surgical decompression within 6 hours; however, current data support surgery within 48 hours.[5] Multiple studies have shown no significant difference in outcomes between early versus late surgery.
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Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Back pain can be broadly described as either acute or chronic. Chronic back pain is persistent or intermittent pain that lasts longer than 3 months. Whereas most cases of acute back pain are self-limited, patients with chronic back pain frequently visit primary care physicians, orthopedists, chiropractors, and physical therapists. Chronic back pain has a substantial economic impact: It has been estimated that the cost of managing back pain exceeds $90 billion annually.[6]
Image courtesy of Wikimedia Commons | Staff Sgt Chris Hubenthal.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Evaluation of lumbar back pain starts with a good history and a thorough physical examination. Given the great breadth of the differential diagnosis, it is critical to ask the right questions while taking the history. Questions should address the subjects of osteoporosis, osteoarthritis, and cancer and should include review of any prior related imaging studies. Physical examination should include a focused neuromuscular examination. A straight leg raise test is a neural tension test that can be used to rule out a herniated disc. In addition, examining for sensation and deep tendon reflexes can help identify the level of pathology.
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Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
A 45-year-old male construction worker presents to his primary care physician's office with a 3-year history of chronic back pain and asks if he can be referred for surgery to "finally" fix the problem. During the history and physical examination, the physician performs a straight leg raise test.
Of all of the following provocative maneuvers and physical findings, which is the most important and accurate predictor for identifying a patient who is a good candidate for surgery?
Spinous process palpation
Pain reproduced with neck flexion, hip flexion, and leg extension
Pain reproduced with straight leg elevation for 30 seconds in the supine position
Straight leg raise reproduces pain and paresthesia in the leg at 30-70° of hip flexion
Image courtesy of Medscape | Sam Shlomo Spaeth.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Answer: D. Straight leg raise reproduces pain and paresthesia in the leg at 30-70° of hip flexion.
A positive straight leg raise test (raising an extended leg to evaluate for pain from 30° to 70° of elevation) is a provocative test for tension on the L5-S1 nerve root. The straight leg raise test can be done with the patient either sitting or supine. Elevation of the leg at 30-70° degrees of hip flexion will reproduce pain and paresthesia in the extremity. This is the most important and predictive physical finding for identifying patients who are good candidates for surgery.
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Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
With respect to imaging, most patients with chronic back pain can have abnormal findings on MRI, but the clinical significance of these findings is not always clear. Likewise, asymptomatic patients may have specific findings on MRI. Therefore, the use of MRI should be limited to those patients with chronic back pain whose examination raises concerns about acute or rapidly progressive disease or those who have radicular symptoms that do not resolve after 6 weeks.[6]
Image courtesy of Wikimedia Commons | Edave.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
A 42-year-old woman presents with right leg pain localized to the buttock, posterior thigh, and lateral calf. In addition, she describes numbness and tingling on the dorsum of the right foot. After 3 months of nonoperative treatment (including anti-inflammatory medication, physical therapy, and steroid injections), she has not obtained lasting relief, and her pain is still severe. MRI is ordered, with the results shown in the slide.
What is the most appropriate next step in management?
What is the most appropriate next step in management?
CT of the lumbar spine
Repeat steroid injection
Refer the patient to pain management
Refer the patient to physical therapy
Surgery
Image courtesy of Wikimedia Commons | Edave.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Answer: E. Surgery.
The patient's clinical presentation and imaging studies are consistent with a disc herniation at L4-5, which is compressing the L5 nerve root. Because nonoperative management has already been attempted, without success, surgical treatment (laminotomy and discectomy) would be the most appropriate next step.[7]
The highest quality data on the topic come from the Spine Patient Outcomes Research Trial (SPORT).[8] However, the results of this randomized, controlled trial are difficult to interpret because adherence to the assigned treatment strategy was suboptimal. Only half the patients who were randomly assigned to the surgery group actually underwent surgery within 3 months after enrollment, and 30% of the patients assigned to nonoperative treatment chose to cross over to the surgical group. In this study, the patients who underwent surgery had greater improvements in validated patient-reported outcomes. The treatment effect of microdiscectomy was superior to that of nonoperative treatment at 3 months, 1 year, and 2 years. Moreover, in an as-treated analysis, the outcomes among patients who underwent surgery were superior to those among patients who received nonoperative therapy. Overall, the results of SPORT support the use of microdiscectomy in this case.
Image courtesy of Wikimedia Commons | Blausen.com staff.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
The goals of managing chronic low back pain ultimately shift from achieving cure to alleviating pain and improving function by pharmacologic and nonpharmacologic means. It is important that the patient's expectations be appropriately managed. Unrealistic expectations, including complete resolution of pain and return to full previous activity, must be addressed. Treatment should begin with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs); the latter must be used with caution because they can have significant gastrointestinal (GI) and renal effects. Opioids and other adjunctive medications may benefit patients whose pain is not relieved by NSAIDs. Muscle relaxants may provide short-term relief of pain with return of function; however, sedation is a common side effect.
Image courtesy of Dreamstime.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
A 27-year-old man presents with a 3-day history of atraumatic low back pain. He denies experiencing constitutional symptoms and reports no bowel or bladder difficulties. Physical examination reveals full motor strength and sensation. No pathologic reflexes are detected.
At the initial visit, which of the following would not be appropriate?
Physical therapy
Limited pain medication
Muscle relaxants
X-rays
Reassurance
Image courtesy of Dreamstime | Emil Zhelyazkov.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Answer: D. X-rays.
A previously healthy patient with acute-onset nontraumatic lower back pain does not need diagnostic imaging before receiving treatment. In this case, the physical examination yielded normal results, with no focal neurologic deficits. The appropriate treatment for acute-onset lower back pain is symptomatic therapy alone. Diagnostic imaging is not warranted unless the initial treatment is unsuccessful and symptoms are prolonged.
Image courtesy of Dreamstime | Yanik Chauvin (background).
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Patients with low back pain commonly seek nonpharmacologic treatment options. About 45% of patients with low back pain see a chiropractor, 24% use massage, 11% undergo acupuncture, and 7% try meditation.[9] Exercise therapy, which involves strengthening and stabilizing core muscle groups of the abdomen and back, appears to yield small improvements in pain and function. However, in a Cochrane review, only six of 43 studies demonstrated clinically and statistically significant differences between intervention and control groups.[10] Acupuncture and massage are only mildly helpful for reducing chronic low back pain. Massage may be beneficial in combination with exercise and stretching.[11] Epidural steroid injections may be indicated in patients with severe radicular symptoms. Patients have shown small improvements for as long as 3 months.[6]
A systematic review of the evidence on nonpharmacologic therapies for acute or chronic non-radicular or radicular low back pain shows that several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain.[12] Findings in this study include new evidence on mind-body interventions. New evidence indicates that tai chi (strength of evidence [SOE], low) and mindfulness-based stress reduction (SOE, moderate) are effective for chronic low back pain and strengthens previous findings regarding the effectiveness of yoga (SOE, moderate). Evidence continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). Limited evidence shows that acupuncture is modestly effective for acute low back pain (SOE, low). The magnitude of pain benefits was small to moderate and generally short term; effects on function generally were smaller than effects on pain.[12]
Image courtesy of Wikimedia Commons.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
A 73-year-old man is admitted to the hospital for severe bilateral buttock and leg pain with ambulation, which has not improved with nonoperative management. MRI is performed, with the result shown in the slide. A surgical lumbar decompression is planned.
Which of the following is the most powerful preoperative factor for predicting clinical outcomes with surgical treatment of this condition?
Smoking
Multilevel spinal stenosis
Comorbid medical conditions
Household income
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
Answer: C. Comorbid medical conditions.
The clinical presentation and the results of MRI support the diagnosis of lumbar spinal stenosis. The presence of comorbid medical conditions (eg, obesity, hypertension, and hyperlipidemia) is the most powerful preoperative prognostic factor for clinical outcomes with surgical treatment of lumbar spinal stenosis.[13,14]
Image courtesy of Wikimedia Commons | Blausen.com staff.
Back Pain: Find the Cause, Watch for the Comeback
Brian Hamzavi, MD | September 15, 2020 | Contributor Information
For patients who have persistent pain or those in whom other treatment options are no longer bringing about any progress, referral to a pain management specialist is appropriate. An epidural steroid injection (shown) may be effective.
Here's a step-by-step guide to spinal decompression surgery. Our surgeon demonstrates key steps of spinal fusion surgery, protecting the patient from nerve injury.Slideshows, April 2017
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Contributor Information
Brian Hamzavi, MD
Orthopaedic Sports Medicine Surgeon
Melbourne, Florida
Disclosure: Brian Hamzavi, MD, has disclosed no relevant financial relationships.
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References
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Sherman KJ, Cherkin DC, Connelly MT, et al. Complementary and alternative medical therapies for chronic low back pain: What treatments are patients willing to try? BMC Complement Altern Med. 2004;4:9.
van Tulder M, Malmivaara A, Hayden J, Koes B. Statistical significance versus clinical importance: trials on exercise therapy for chronic low back pain as example. Spine. 2007;32(16):1785-90.
Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929.
Biyani A. Andersson GBJ. Low back pain: pathophysiology and management. J Am Acad Orthop Surg. March/April 2004;12:106-15.
Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81.
Ramaswami R, Ghogawala Z, Weinstein JN. Management of Sciatica. New England Journal of Medicine. 2017; 376(12): 1175-1177.
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006; 296: 2441-2450.
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001 Feb 1;344:363-70.
Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335.
Kamali F, Panahi F, Ebrahimi S, et al. Comparison between massage and routine physical therapy in women with sub acute and chronic nonspecific low back pain. J Back Musculoskelet Rehabil. 2014;27(4):475-80.
Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. [Review] Chou R; Deyo R; Friedly J; Skelly A; Hashimoto R; Weimer M; Fu R; Dana T; Kraegel P; Griffin J; Grusing S; Brodt ED. Annals of Internal Medicine. 166(7):493-505, 2017 Apr 04.
Ma XL, Zhao XW, Ma JX, et al. Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: A system review and meta-analysis of randomized controlled trials. Int J Surg. 2017;44:329-338.
Covaro A, Vila-Canet G, de Frutos AG, et al. Management of degenerative lumbar spinal stenosis: an evidence-based review. EFORT Open Rev. 2017;1(7):267-274.
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