Page 1 of 4 Dr. RAJENDRAN’S INSTITUTE OF MEDICAL EDUCATION LOW BACK PAIN - DIAGNOSIS AND MANAGEMENT Low back pain is pain localized to the lumbar area between the inferior ribcage and the waistline. It may include sciatica (pain radiating down the posterior-lateral thigh distal to the knee). It has commonly been divided by duration into acute (<6 weeks), subacute (6 to 12 weeks), and chronic (longer than 12 weeks). 1) What are the most common causes? There are 4 general causes: nonspecific, mechanical, nonmechanical, and referred visceral. Nonspecific (70%) Lumbar sprain/strain Mechanical (27%) Degenerative disc/facet disease Herniated disc Osteoporotic fracture, usually compression Spinal stenosis Spondylolisthesis Visceral/referred, nonmalignant (2%) Aortic aneurysm Pelvic organ diseases (prostatitis, endometriosis, pelvic inflammatory disease) Gastrointestinal disease (pancreatitis, cholecystitis, penetrating peptic ulcer) Renal disease (nephrolithiasis, pyelonephritis) Nonmechanical (1%) Neoplasia (multiple myeloma, metastatic carcinoma, lymphoma, leukemia, spinal cord tumors, retroperitoneal tumors, primary vertebral tumors) Inflammatory arthritis, often HLA-B27-positive (ankylosing spondylitis, psoriatic spondylitis, Reiter syndrome, inflammatory bowel disease) Infection (osteomyelitis, septic discitis, paraspinous abscess, epidural abscess, perinephric abscess, shingles)[a] Scheuermann disease (osteochondrosis) Paget disease of bone www.medicinemcq.com Page 2 of 4 2) What is the clinical importance of “red flags”? The first goal is to evaluate for dangerous causes that could result in significant morbidity and mortality. Red flags are findings that suggest underlying infection or malignancy or the need for immediate surgical attention. See table below. While most cases of low back pain spontaneously resolve, the clinician must be alert to clinical indicators or “red flags” that suggest the presence of systemic illness or imminent neurologic compromise. This approach helps to identify the small percentage of patients who have serious pathology as the underlying cause of their pain. In the absence of such findings, diagnostic imaging generally does not contribute to management, and may be safely delayed for a trial of conservative therapy. RED FLAGS FOR POTENTIALLY SERIOUS CONDITIONS Historical Red Flags Physical Red Flags Age <18 or >50 y Fever Pain lasting more than 6 wk Writhing in pain History of cancer Bowel or bladder incontinence Fever and chills Saddle anesthesia Night sweats, unexplained weight loss Decreased or absent anal sphincter tone Recent bacterial infection Perianal or perineal sensory loss Unremitting pain despite rest and analgesics Severe or progressive neurologic defect Night pain Major motor weakness Intravenous drug users, immunocompromised Major trauma Minor trauma in the elderly www.medicinemcq.com Page 3 of 4 3) What is the clinical importance of “yellow flags”? “Yellow flags” are psychosocial barriers to recovery. The “yellow flags” are a combination of behaviors, beliefs, work history, social factors, and affective symptoms. See table below. YELLOW FLAGS FOR LOW BACK PAIN PROGNOSIS Affective Depression and symptoms of depression Anxiety and symptoms of anxiety Irritability Behavioral Poor coping skills Impaired or excessive sleep Passive attitude about and poor compliance with rehabilitation Dramatically reduced activities of daily living Social withdrawal Increased use of alcohol or other substances of abuse Belief Catastrophic thinking Belief that pain is uncontrollable Belief that pain is physically harmful Belief that pain must be completely eliminated before returning to work Misinterpretation/exaggeration of other somatic symptoms Expectation of a technological solution for back pain Social Lack of support system Overprotective family/friends Socially punitive family/friends Low educational background History of physical, sexual, or substance abuse Occupational Expectation of worsening pain or setbacks with activity Poor work history, frequent lost time Poor job satisfaction Unsupportive work environment Problems with claims and compensation Pending litigation www.medicinemcq.com Page 4 of 4 4) How will you determine the likelihood of serious illness? History Rapidly obtain a targeted history to ……………. For complete article, click 'premium contents' at the top of the home page and then → Orthopedics → Low back ache. References Low back pain: an approach to diagnosis and management. Duffy RL - Prim Care - 01DEC-2010; 37(4): 729-41 Appropriate use of lumbar imaging for evaluation of low back pain. Chou R - Radiol Clin North Am - 01-JUL-2012; 50(4): 569-85 The emergency department evaluation, management, and treatment of back pain. Corwell BN - Emerg Med Clin North Am - 01-NOV-2010; 28(4): 811-39 Low Back Pain. From: Daroff: Bradley's Neurology in Clinical Practice, 6th ed.; Chapter 73 - Disorders of Bones, Joints, Ligaments, and Meninges Chapter 11. Pain in the Back, Neck, and Extremities. Adams and Victor's Neurology Chapter 15. Back and Neck Pain. Harrison's Online From: Goldman: Goldman's Cecil Medicine, 24th ed.; Chapter 407 - Mechanical and Other Lesions of the Spine, Nerve Roots, and Spinal Cord www.medicinemcq.com