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• CHAPTER
24 Low Back Pain (Acute) A report of acute low back pain (ALBP), ~}though quite common, requires a thor ough evaluation. The underlying pathophysi o logy of back pain is frequently multifactorial and includes both physiological and psy chological components . The most common causes ofALBP relate to musculoligamentous injuries and age-related degenerative pro cesses. A bout 90% of ALBP episodes in adults are related to mechanical causes that resolve within 4 weeks without serious se quelae. A smaller percentage of patients will continue to have chronic symptoms without organic pathology or have underlying disease.
In chi ldren, the prevalence of back pain increases with age and with involvement in sports. Anthropometric variations in children place them at risk for excess strain on the spine, producing back pain. These variations include reduced hip mobility, decreased lum bar extension and increased lumbar flexion , poor abdominal muscle strength, tight ham string muscles, and lumbar hyperlordosis.
Acute low back pain is defined as activity intolerance producing lower back or back related leg symptoms of less than 3 months ' duration. The Agency for Healthcare Research and Quality (AHRQ) guidelines provide the fo llowing framework for causes of ALBP: • Potentially serious conditions (e.g., spinal
fracture, tumor, infection, or cauda equina syndrome)
• Sciatica, or leg pain and numbness of the lateral thigh, leg, and foot, suggesting nerve root compression (Fig. 24. I)
• Nonspecific back problems such as mus culoskeletal strain, diskogenic pain, or bony deformity secondary to inflamma tory diseas e
• Nonspinal causes secondary to abdominal involv~ment (e.g., gallbladder, l iver, renal,
336
pelvic inflammatory disease, prostate tumor, ovarian cyst, uterine fibroids, aortic a n eurysm, or thoracic disease)
• Psychological causes such as stress related to work environment (e.g ., disability, workers' compensation, secondary gains). When evaluating ALBP, the goal of the
clinician is to first identify signs and symp toms of potentially serious conditions through a careful history and physical examination. A holistic approach to the patient is needed to appreciate the extent to which pain affects the patient' s daily routine or work- related activi ties. Because ALBP is a common occupation related complaint and a cause of disability and lost productivity, the clinician must gain insight into the patient's psychosocial and economic situation to help arrive at a correct diagnosis.
DIAGNOSTIC REA s n.:. )NG: FOCUSED HISTORY
Is this a potentially serious cause ofALBP?
Key Questions • Do you have a fever? • Have you experienced any trauma to the
spine or back? • Do you have any other health problems? • Have you b een treated for cancer? • What is your age? • Have you had loss of control of your
bowels or bladder? • Are you taking any medications?
Fever The pre sence of a fever indicates an inflamma tory condition such as spondyloarthropathy or systemic infection. Infection is a likely diag nosis when there are chills and fever, weight loss, a recent history of bacterial infection,
Chapter 24 • Low Back Pain (Acute}
Nerve root
Pain
Numbness
Motor weakness
Screening examination
Reflexes
f.1GURE 24.1 Testin g for lumbar nerve root compromise. (From Bigos S, Bowyer OR, Braen GR, et a l : A c ute /ow back problems in adults, clinical practice guidelines, Quick Reference Guide Number 14, Rockville , ~d., 1994, Department of Health and Human Services, U.S. Public H ea lth Service, Age ncy for H ealt h Care Policy and Research, AHCPR Publication No. 95-0643.)
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Extension of Dorsiflexion of Plantar flexion quadriceps great toe and of great toe
foot and foot
Squat and rise Heel walking W a lking on toes
Knee jerk None reliable Ankle jerk diminished diminished
Jntravenous drug use, or immunosuppression. Ewing sarcoma is a malignant tumor and can mimic spinal infection, occu rring as back pain that can be accompanied by fever. Children ~ith discitis will h ave a fever and refuse to ~alk because of back pain. In adu lts, vertebral
steomyel iti s or disciti s occurs mos t ofte n as a esult of h ematogenou s seedi n g of S. aure us, troduced through invasive procedures or
urgery. Pain localizes over the infected disc rea and is made worse with physical activity.
Pain may radiate to the a bdomen, leg, scro tum , gro in, or perineum.
Trauma Acute trauma to the spinal cord can result in fracture, dislocation, or damage to muscles, ligaments, and intervertebral disks. Trauma may be cau sed by blunt impact, repetitive in jury, or s udden str ess caused by lifting or pulling. Low back p a in is the most common occupational injury reported, so knowing a
Chapter 24 • Low Back Pain (Acute)
patient's occupation helps assess specific risk factors. Injury to the back usua]]y results in contusions and abrasions but can a]so cause spinal fracture if the force is major, such as that sustained in a motor vehicle accident or fa]J. Adults can have an acute compression spinal fracture as a result of strenuous lifting when osteoporosis is present. Most cases of ALBP in adolescents who are athJeticaHy ac tive are caused by injury to the posterior structures of the spine.
Injury to the spinal column should be suspected in anyone whose level of con sciousness is impaired after an accident. Cervical , thoracic and lumbar spine fractures are sustained during flexion, extension, com pression, rotation, or a combination of forces.
Systemic Disease and Cancer Metabolic disease , inflammatory disorders, and fibromyalgia can lead to back pain. Patients with a history of cancer may have increased risk of a metastatic spinal tumor. Neuroblastoma is common in young chil dren , and although it occurs in the abdomen, metastases to the spine may produce back pain. People younger than 20 years and older than 50 years are at increased risk for tumor, as are those with a history of cancer.
Age In the absence of trauma, the sudden onset of severe low or middle back pain in people older than 30 years might suggest a dissecting aortic aneurysm; the pain is not alleviated by rest. Patients older than 50 years are at increased risk for compression fracture as we11 as cancer.
Bowel and Bladder Sy mptoms Loss of urinary or stool c o ntinence are early s igns of conus rnedulari s syndrome (verte bral involve ment at L2) and late signs of cauda equina s yndrome which involv e s nerve root compromise in the lower lumbar and sacral nerve roots secondary to a herniate d disk, nerve root entrapment, spinal stenosis, infection, or tumor. Cauda equine is considered a surgical emergency. Other symptoms include constant lumbar pain with saddle anesthesia, urinary retention or overflow incontinence, and fecal incontinence due to an atonic anal sphincter.
Cauda equina Children are embarrassed to talk about urj. nary or bowel habits and changes . Hidder spinal cord tumors might have a relation. ship to deve l opmental delays in bladde1 and bowel control. Children younger than 4 years of age who have back pain should be evaluated for serious diseases, such as intra spinal tumors , dermoid cysts, and malignant astrocytomas.
Medications Long-term use of corticosteroids can lead to compression fractures of the vertebrae. Use of intravenous drugs may suggest infection as a cause.
What does the location ofpain tell me?
Key Question • Where does it hurt?
Location of Pain In general, children are less specific than adults when describing location of pain. Traumatic lesions are more likely to occur in the cervical and lumbar portions of the spine, where there is more motion and less protection. General ized pain or pain over a fairly wide anatomical area is frequently seen with overuse problems and inflammatory conditions.
Sciatica pain is a sharp, burning pain that radiates down the posterior and lateral leg to the foot or ankle . Rheumatoid arthritis pro duces pain in the upper back and neck. Local ized pain is seen with spondylolysis and tumors. Flank pain in adults may indicate a kidney infection. Pain from gallbladder disease radiates to the subscapular areas. Compression fractures of vertebrae associated with osteopo rosis or malignancy may produce pain over the area where the fracture has occurred.
Chi ldren with traumatic low back derange ment will have pain and muscle spasm in the lumbar area from the shock ofan impact injury.
What does the pattern ofpain t ell me?
Key Questions • When did the pain start? • How long have you had this pain?
Chapter 24 • Low Back Pain (Acute)
What does the pain feel like? • Does it interfere with s leep? • Ha e you had this pain before?
onset The onset of ALBP is sudden, and more than half of patients do not associate it with a spe cific precipitating event or injury. The vast majority of cases of ALBP resolve with con servative treatment in 4 weeks, and radio graphic or further diagnostic studies are not recommended unless it associated with trauma or symptoms such as radiating pain to an extremity, extremity weakness or bladder or bowel dysfunction.
Children are frequently poor historians, and parents may have a difficult time remem bering when the pain started. Association with events such as birthdays, holidays, and activi ties is helpful in establishing the onset of a child's pain. Mild pain of short duration (1- 2 weeks) is rarely serious.
Back pain lasting longer than 4 weeks needs to be reevaluated for further diagnostic studies.
Duration Subacute back pain is of 6 to 12 weeks' dura tion. Chronic back pain is pain lasting for more than 3 months. In people younger than 40 years of age, the cause may be postural, related to weak abdominal or back muscles, or may indicate congenital spinal deformity, such as scoliosis or ankylosing spondylitis. In older people, chronic back pain is more likely to indicate degenerative disease, such as spi nal stenosis or disk herniation. In children, back pain present for more than 3 weeks is often caused by organic and serious causes.
Pain Characterist ics lo chi ldren, express ion of pain depends on the child's ability to put feelings of pain into behavior; observing for these behaviors is important. Ask childr en to rate the pain using a IO-point pain s c a le with happy to sad faces (see Chapter 3 ). A s k adults to rate pain from 0 (no pain) to 10 (worst pain ever) and assess how much the pain interferes with daily ac tivities. Intractable back pain, especially night pain with constitutional findings, i s li kely to indicate neoplastic disease. Hyperalgesia is
increased sensitivity to pain in damaged tissue; this can develop after long-term use of opioids for chronic pain.
Night Pain Nighttime back pain is a worrisome symptom that often signals a serious problem, such as tumor, infection, or inflammation. Generally, muscle strains, overuse injuries, spondyloly sis, spondylolisthesis, and Scheuermann dis ease (an exaggeration of the normal posterior convex curvature of the thoracic spine) pro duce less pain at night. Morning stiffuess that improves as the day progresses suggests osteoarthritis or ankylosing spondylitis.
Nighttime back pain is unusual and indicates the need for a complete and thorough workup.
Recurring Pain Back pain in young children who have had previous injuries or fractures may be a symp tom of child abuse. In older adults, it may be an indication of compression fractures of the spine. As with young children, it may also signal abuse by a caregiver.
What does the pain in relation to activity tell me?
Ke y Questions • What makes the pain worse? • What makes the pain better? • School children: do you carry a backpack?
Aggravating Factors Pain in the lumbar area after strenuous sport ing activities is usually the result of trauma to the muscles and tendons, causing contusions and sprain. It occurs when the patient pushes the muscles and ligaments past the normal level of tolerance. Repeated injury can cause soft tissue scarring and shortening.
Stress and fatigue fractures of the pars in terarticularis, the region between the superior and inferior articulating facets of the vertebra, occur when lumbar lordosis places more stress on the pars, such as in gymnastics and tennis.
Pain that is aggravated by activity is usually musculoskeletal in origin. Pain of ankylosing spondylitis is relieved with exercise. Spinal
Chapter 24 • Low Back Pain (Acute)
stenosis is associated with increased pain with stand.in& sneezing, or coughing. In an active aduJt, poor preparation before exercise can lead to back injwy and pain. Severe low back pain is often the first symptom reported with spinal cord compression. When pain is not improved with lying down it suggests cancer or infection. Pain with movement suggests vertebral instability.
Any child who has voluntarily given up a pleasurable activity because of back pain has a severe symptom.
Alleviating Factors Back pain not associated with any activity and not relieved by rest may indicate tumor. In children, back pain relieved with aspirin or nonsteroidal antiinflammatory drugs may indicate an inflammatory cause. Pain that is alleviated by rest and heat indicates a muscu loskeletal cause. Pain of spinal stenosis is relieved by flex ion of the spine.
Suspect spondylolisthesis, or forward slip page of one vertebra over another, if the onset of pain is during hyperextension, which can occur with a back handspring, butterfly stroke in swimming, or a tennis serve. The defect can be the result of degenerative processes in older patients or arise from a stress fracture or stress reaction of the isthmus of the pars inter articularis in the area of L5 to SI. The pain localizes to the low back and occurs during a growth spurt and after engaging in sporting events. The pain improves with rest and is worse with standing.
Backpack School children often cany heavy backpacks, increasing the risk of b ack pain and injury.
What does radiation of1miu 11:·ll r.u! ?
• Does the pain travel? • Can you show me where the pain travels?
Radiation of Pain Referred pain is of two types: (1) pain referred from the spine into areas lying within the lum bar and upper sacral dennatomes and (2) pain referred from the pelvic and abdomina l viscera to the spine. Pain from the upper lumbar
spine us ually radiates to the anterior aspects of the thighs and legs, and pain from the lower lumbar spine radiates to the gluteaJ regions, posterior thighs, and calves (see Figure 24.4).
Pain from visceral di sease is us ually felt within the abdomen or flanks. Gallbladder pain radiates around the trunk to the right scapula. Position does not affect the pain.
ln children and adolescent athletes, spondy lolysis typically represents a fracture of the posterior arch in the lower lumbar s pine due to overuse and is a relatively common cause of low back pain. Spondylolisthesis, an anterior displacement of a vertebra, is less common. Patients often develop pain that spreads across their lumbar region and radiates into their buttocks or posterior legs.
Pain that is sharp and burning and radiates down the lateral or posterior aspect of the leg to the lateral ankle or foot is called sciatica and is a classic symptom of nerve root irrita tion most often caused by disk herniation.
Are there signs ofneurological damage?
Key Questions • Have you been stumbling? • Have you noticed any change m your
balance or coordination? • Does the child frequently stumble or fall? • Do you have numbness or tingling in your
extremities?
Stumbling Spinal cord twnors, such as astrocytoma or epen dymoma, may present as a disturbance of move~ ment, posture, or strength in the spine or extremi ties . lmpainnent of proprioception or sensation from an upper motor neuron lesion, exhibited by foot drop or ataxia, may produce stumbling.
Numbness and Tingling Radiculopathy (nerve root pain) is sharp pain fe lt in a dermatomal pattern and is sometimes a ssociated with numbness and tingling.
ls there a family history of back pain?
Key Question • Does anyone in your fan1ily have scoliosi
or a crooked spine?
Chapter 24 • Low Back Pain (Acute)
Does Lou• Back Pain in Adolesce11ts2 EVIDENCE-BASED PRACTICE /11tficllte a Serious Prob/e111?
Astudy of more than 200,000 adolescents who presented to a health care provider with low back pain were followed for 1 year. At 1 year, more than 80% of the adolescents had no identifiable diagnosis. The most common diagnoses found at
1 year were lumbar sprain-strain, less than 8%; scoliosis, less than 4 %; and lumbar degenerative disk disease, less than 1%. Spondylolysis, spon dylolisthesis, i nfection, tumor, and fracture had a less than 1 % association with LBP.
Reference: Yang et al , 201 7.
Family History Spondylolysis and scoliosis are often seen in families, with a 40o/o familial occurrence in Native Alaskans.
Could this pain be caused by systemic disease?
Key Question • Have you been ill?
Illness Pharyngitis or upper respiratory tract infec tions, such as pneumonia, can be the precur sor to diskitis, inflammation of the vertebral disk space, in children. The intervertebral disk in children receives its blood supply from the surface of the a djacent vertebral bodies, providing the mechanism necessary for infection. Uveitis and iritis may be associ ated with juvenile rheumatoid arthritis or juvenile ankylosing s pondylitis.
A female patient with pelvic inflammatory disease (PID) may h ave mild to moderate dull, aching, lower abdominal, pelvic, or possibly back pain. With pyelonephritis, the patient may report fever, nausea and vomiting, head ache, and back or flank pain. A urinary tract infection may present as back pain.
DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAM INATION Observe the Patient's General Appearance and Behavior Any person appearing ill with a fever, limp, or unwillingness to walk is highly suspect for having an infectious cause of back pain; how ever, a number of these symptoms may have
a psychological component that should be explored.
Observe for symmetry of posture and movement from direct anterior, posterior, and lateral views ofthe patient. Note the amount of thoracic kyphosis (anteroposterior curve) and lumbar lordosis (anterior convexity) and the alignment of the head and neck above the center of gravity. Children with diskitis often protect their backs by sitting in a hyperex tended position, u sing the arms as support, and may lie down and cry if they are made to sit.
Observe Gait Shifting or leaning to one side (listing) and atypical scoliosis may indicate a tumor. List ing is caused by asymmetric sustained muscle contraction. The spinal curvature serves to relieve the discomfort and reduce pressure on a nerve root.
Severely affected gait in spondylosis is caused by hamstring tightness and results in uneven s tride length with a persistently fixed knee to prevent hip flexion, which would stretch the tight hamstring muscles and increase pain.
Assess Vital Signs Fever may indicate systemic infection as well as diskitis. Unexp la ined weight loss may suggest n eoplasm, infection, or depression.
Examine Skin Dermal cysts or a h a iry patch over the s pine may indica te spina l a nomaly or tumor.
A doughy, fatty m ass in the midline of the back (sometimes covered with h air [a Faun beard]) is evidence of a lipoma, which may extend into the spi nal cord and produce n eurologic symptoms.
Chapter 24 • Low Back Pain (Acute)
Examine Eyes, Ears, Nose, and Mouth Uveitis iritis is seen in juvenile rheumatoid arthritis and ankylosirtg spondyli tis. P h aryn gi tis, otitis media, or infect ion of h ematogenous origin may be t he cause of diskitis in chi ldren.
Inspect the Back and Extremities Observe for spinal a lignment and symmetry of the t ips of the scapula, iliac crests, and g lutea l crease. If ind icated, measure and compare leg lengths from the anterosuperior ili ac crest to th e medial mal leo lus. Measurements can be performed with the patient standing or sup ine. Legs should be of equal length or have less than 1 cm differen ce in length. Leg length dif ferences are associated with pathologic condi tions of the sacroiliac, facet joint, and disk.
From posterior and lateral viewpoints, observe the patient bending forward with feet together to detect scoliosis, kyphosis, or stiff ness and guarding.
Percuss and Palpate Back and Spine Painful scoliosis and stif:llless are common in osteoid osteoma. I diopathic scoliosis is usu a lly painless without functional limitation . Point tenderness over the affected area is a finding associated with a compression fracture of the vertebrae or an infection of the spin e.
Palpate and percuss the back to determine if tenderness is in the paravertebral muscular or midline spinou s processes, which may
indicate diskitis or osteomyelitis. To rule out the sacroi li ac joint as the si te of origin of ALBP, cond~ct ~ FABER . test (~ig. 24.2). Place the patient m the supme pos itio n . Flex the leg and put the foot of the tested leg on the opposite knee. The motion is that of tlexion abduction , external rotation at the hip. Slow1; press down on the superior aspect of the tested knee joint lowering the leg into further abduction. The test result is positive if there is pain at the hip or sacral joint or if the leg can not lower to the point of being parallel to the opposite leg.
Use fist percussion over the costovertebral angles to discriminate flank pain caused by renal disease from spinal pathology. Apply fist percussion over the costovertebral angles and over the spine to localize tenderness.
Perform Range of Motion of the Spine Ask the patient to flex, extend, rotate, and bend the spine laterally. Decreased mobility and back pain along the spine may indicate muscle spasm, neoplasm, or bony deformity. Pain with forward flexion usually indicates a mechanical cau se. Back exten sion pain increases with spinal stenosis.
Look for compensating effects of hip motion on the spine. The absence of lumbar flexion may be totally masked by a normal range of hip flexion when the patient bends forward. Test lumbar flexion by placing a mark
FIGURE 24.2 The FABER maneuver (flexion, abduction, externa l rotation at the hip) . (From Cummings Stanley-Green S, Huggs P: Perspectives in athletic training, St. Louis, 2009, Mosby.)
--
I
Chapter 24 • Low Back Pain (Acute) I 343
0 ,,er the fourth lwnbar vertebra and another
over the sacrum. Lumbar flexion is demon strated by an increased distance between these rwo marks when the patient bends forward.
A modified Schober test can be used to assess lumbar mobility. With the patient standing erect and heels together, draw a mark on the skin 5 cm below an imaginary line be rween the buttock dimples overlying the pos terior superior iliac spine. A second mark is made 15 cm above this line. Then have the patient bend forward touching their toes. An increase in distance between these lines of 6 cm or more is normal; less than 6 cm indicates decreased lumbar spine mobility (Fig. 24.3).
Observe for limitation of motion on for ward bending caused by hip flexion contrac ture. Lumbar lordosis does not flatten with forward bending and is an organic cause for back pain. In children, Scheuermann disease, an exaggeration of the normal posterior con vex curvature of the thoracic spine, produces pain with forward flexion , and spondylolysis produces pain with hyperextens ion.
Perform Straight Leg Raising The straight leg raising (SLR) test can assess sciatic (L5 and S 1) nerve root tension. With the patient supine, place one hand above the knee,
the other cupping the heel, and slowly raise the limb. Instruct the patient to say when to stop because of pain. Observe for pelvic movement and the degree of leg elevation when the pa tient tells you to stop. Ask the patient to tell you the most distal point of pain sensation, such as the back, hip, thigh, or knee. While holding the leg at the limit of elevation, dorsiflexing the ankle and internally rotating wi ll add tension to the neural structures and increase the pain if nerve root tension is present.
Pain below the knee at less than 70 de grees of elevation that is aggravate d by dorsiflexing the ankle or hip rotation is a sign of LS or S 1 nerve root te nsion, sugges tive of a herniated dis k. This test can also be performed with the patient sitting. In a positive test res ult, the patient will resist extension or will compensate with hyperex tension of the spine.
Lift each leg in succession to detect con tralateral pain in patients with nerve root compression.
Results of the SLR test in children with a tumor can be unremarkable.
Check Hip Mobility With the patient prone and supine, check active hip flexion , extension, interna l and external
Finger-to-floor distance
Modified Schober test (normal: total >20 cm)
t ·.i: cm S2 -----r- . -
T · ~n·1---:r- . -'-·• I
/ ---l~~-cm , S2 - - - - - - -
5cm
Finger-to-floor ~---- distance
B Flexion
FIGURE 24.3 Performing the modified Schober test for spina l flexibility. (From Lawry G, Kreder H, Hawker G, Jerome D: Fam's musc uloskeletal examination and joint injection techniques, ed. 2, Philadelphia, 2 011, M osby.)
Chapter 24 • Low B ack Pain (Acute)
rotation , and strength against resistance. Weak ness of the gluteus maxi mus is associated with lumbar or referred pain from LS nerve roots or gluteal nerve injury. In small children, check for congenital hip dysplas ia with the child su pine and abducting the hips (see C hapte r 22). The knees s h ould appear of equal height and should rotate externally by equal degrees. The presence of a hip c lick, joint instability, uneven hip-to-knee length with hips and knees flexed , and uneven gluteal skinfolds suggests congen i tal hip dislocation.
Examine Feet Perform active range of motion of the ankle, feet, and toes against resistance. Weakness, pain, or limitation of dorsiflexion movement indicates an L4 nerve root injury. Similar symptoms produced by plantar flexion indi cate S 1 involvement, while symptoms pro duced by dorsiflexion of the big toe indicate LS involvement. Deformities of the foot, such as talipes equinovarus (clubfoot) or hallux malleus (claw toes) , may aggravate misalignment of back structures because of asymmetry.
Evaluate Muscle Strength Evaluate strength against resistance of the lower extremity muscle groups. Test the pa tienCs ability to stand on the toes and heels and to squat. A person with SI nerve root in volvement may have little motor weakness but may demonstrate difficulty in toe walking. Difficulty with heel walking or squatting indi cates invo lvement of LS and L4 nerve roots. Leg extension at the knee against resistance tests L4 root function. In young children who are unable to cooperate for measurement of muscle strength, use measure ments of s imilar limb girths as an estimate of the bilateral sym metry of muscle strength.
Measure Muscle Circumter em·;e Differences in muscle circumference greater than 2 cm in two opposite limbs may signify atrophy secondary to neurologic impairment.
T~~~t. Sensory Function Neurologic test res ults are evaluated by comparing the symmetry of responses or
perceptions. Bilateral comparison is the sirn. plest, most efficient way to detennine the presence, location, and ex tent of any abnor mality. A sensory examination is a general guide in determining the level of spinal cord involvement. Test for light touch and pain sensation in the sensory areas of L3 to SJ dermatomes (see Fig. 24.4). Dennatornes overlap a nd vary greatly in individuals; thus
' on ly gross chan ges can be detected by pinprick. Test 5 to l 0 pinpricks in each der matomal area if the patient reports numbness and tingling. Disk lesions rarely produce bilateral symptoms. It is sometimes difficult to distinguish numbness from a cutaneous nerve versus a dennatomal origin. Numbness from cutaneous nerve lesions does not occur in a dermatomal pattern. Numbness and tin gling are uncommon symptoms in most chil dren with back pain. When these symptoms are present, it suggests a serious problem.
Assess Deep Tendon Reflexes Normal deep tendon reflexes (DTRs) are symmetrical. DTRs are increased when an upper motor neuron lesion is present and de creased with a lower m otor neuron lesion. A positive Babinski sign indicates a disorder of upper motor neurons affecting the motor area of the brain or corticosp inal tracts c aused by spinal tumors or demy e linating disease. DTRs are decreased if a tumor is pressing on a peripheral nerve. A symmetric abdominal reflexes are seen in tumors of the spine.
An absent or a decreased ankle-jerk reflex suggests an S 1 nerve root lesion. An L3 to L4 disk herniation is the most common cause of a diminished knee-jerk reflex.
Palpate the Abdomen The abdomen is palpated to detect possible visceral causes of back pain. In adu lts older than 50 years, a ruptured aortic aneurysm can cause acute, severe, midthoracic back pain. If an aortic aneurysm is s uspected, immediate s urgical referral is critical.
Check Rectal Sphincter Tone In cauda equina syndrome, the compression of S 1 to S2 nerve roots results in decreased sphincter tone and decreased sensation in the
Chapter 24 • L ow Back Pa i n (Acute)
AGURE 24.4 Dermatomes of the body, the area of body surface innervated by particular spinal nerves; Cl has no cutaneous distribution. A , anterior v iew. B , posterior view. (From A: Rudy, EB: Advanced neurological andneurosurgical nursing. 1984, M osby, St Louis. 8 : Thibodeau, GA, Patton , KT: Anatomy and physiology. ed 5, 2003, Mosby, St Louis)
perianal area. This syndrome 1s a surgical emergency.
LABORATORY AND DIAGNOSTIC STUDIES
According to national practice guidelines, no diagnostic tests are w arranted within the first 4 weeks for onset of A LBP without neuro logical signs or sympto m s.
Spinal Radiographs Aflat lumbosacral spi n e:! •::ldiograph is obtained when there is a history ~ f trauma or in people older than 50 years who hav e ALBP with s igns of neurologic deficit a his tory of straining or lifting. Anterior and p osterior view radiographs are useful in ruling out :fracture, tumor, osteo phytes (bone spurs), or vertebral infection.
Oblique and flexion views increase the sensi tivity for determining insta bility.
Bone Mineral Density Bone mineral density (BMD) uses radiography to assess the amount of calcium in bone. The dista l wrist and lumbosacral spine can be scanned to assess BMD and the risk of osteopo rosis. Density is measured as a T-score, re ported as the number of standard dev iations that a patient's BMD value is above or below the referen ce value for a h ea lthy 30-year-old adult. AT-score cutoff value for osteoporos is is -2.5.
Bone Scan Bone scanning uses a radioisotope to assess b lood flow and bone formation or d estruction. It can reveal inflammatory and infiltrative processes and occu lt fractures.
Chapter 24 • Low Back Pain (Acute)
2 EVIDENCE-BASED PRACTICE Hou' /111porlt111t Is Obtt1i11i11g Rt1dio1-:raphic /111l1J.:i11g When ll1a11t1gi11g Acute Lo•v Back Pain?
A systematic review and meta-analysis was conducted to compare ca re with and without immediate routine lumbar imaging for ALBP without indications of serious underlying condi tions. Outcomes examined included pain , func tion , mental health, qual ity of life, patient sat isfaction, and overall patient improvement.
Reference : Andersen JC: 2011 .
Electromyography E lec tromyography (EMG) with nerve conduc tion study is a diagnostic proce dure to assess the health of muscles and the nerve cells (motor neuron s) that control them. In n erve conduction e lectrodes are placed on the skin to meas ure speed and strength of s ignals traveling between two points.
Diagnostic Imaging Magnetic resonance imaging (MRI) is useful in evaluating soft tissue detail , such as disk herniations, tumors, and spinal cord patho lo gies, especially in vertebral osteomyelitis. Computed tomography is usually used for bone visualization.
Urinalysis Urinalys is is performed to assess kidney and metaboli c function , including infectious pro cesses, to rule out a v isceral cause of back p ain , such as the pain of pyelonephritis.
Erythrocyte Sedimentation Rat e The erytlu·ocyte sedimentatio n rate ( E SR) will be elevated in about 90°/o of p a tie n ts with a serious mus culoskeletal infection; h owever, there is no direct rela tionship b etwe e n ESR and severity o f infection. The test is nonspecific.
Complete Blood Count The complete blood count will detect anemia as well as other c onditions that might mani fest a s back pain, such as tumor or infection. The a nemia of chronic disease is u s u a lly hy pochromic or normochromic with low iron indices .
Results showed no differences in short-term or long-term follow-up between the group that underwent imaging and the group that did not. In addition to no c linical benefit from immediate imaging w ith ALBP, routi n e lumbar imaging is associated with radiation exposure and increased cost related to u nnecessary procedures.
DIFFERENTIAL DIAGNOSIS Potentially Serious Causes of Acute Low Back Pain
Spinal fracture
The patient may r e la te a history of major trauma to the back from an impact or fall or, if the patient is an older a dult, a history of strenuous lifting or a minor fall. Pain is felt near the site of injury. Any suspicion of spinal fracture should be treated as an emergency. The patient is immobilized t o prevent further damage and transported by emergency per sonnel to obtain radiogra phs of the suspected area of fracture .
Tumor (osteoblastom a, spinal metastasis, osteoid osteoma)
Whereas primary tumors ar e a more common cause of back pain in c h ildren, metastases are a more common cau se in adults. The lower thoracic and upper lumbar vertebrae are the most common sites of bony metastatic disease from marrow tumors . A h ealth history and diagnostic tests may reveal other signs of poor general health, s u c h as weight loss, fati g ue, weakness, and a n emia .
Infe ction (osteomyelitis, dis kitis, epidural abcess)
The spine is t he mos t commo n s ite of osteomy e litis in adults, secondary to a djace nt infection or following invasive instrumentation that results in bacterial seeding of the bone via arte rial blood. Staphylococcus aureus is the most
Chapter 24 • Low Back Pain (Acute)
• tly identified organism. Vertebral osteo fre<lu~~ causes stiffhess and pain. usually local 1l)ictins f . .c. . A d .1 er the site o m1ect1on. ten er spmous · ~..rl 0 t~ positive SLR test result, and paraverte
bProcCSS·uscle spasm may be seen m. verte ral os brtll 111 . d. 1- : . p . h
rnyelitis or septic t SJUtlS. at1ents may ave 1i:° in secondary to involvement of L2 to SI. htP~skitis is usually a benign disorder in
'ldren that results in intervertebral disk ~h~ammation. Children will be reluctant to 10
lk sit or stand. Pain will be aggravated bywa , , otion and relieved by rest. History will re
%a1 a recent bacterial infection, often second ~ry to pharyngitis or otit~s media,_ intravenous drug use, diabetes melhtus, or 1mmunosup pression. A small percentage of adults will report an acute onset of fever, weight loss, and genera l malaise; however, the majority will only have the symptom of back pain, present from 2 weeks to years.
Epidural abscess is a rare and serious in fection of the central nervous system (CNS). Abscesses that occur within the bony confines of the skull or spinal column can expand to compress the brain or spinal cord and cause severe symptoms, permanent complications, or even death. Prompt diagnosis and treat ment is critical and treatment often includes aspiration guided by magnetic resonance im aging or surgical drainage of the abscess.
Herniated disk
Disk herniation caus es nerve root irritation and produces ALBP that radiates down the buttock to below the knee. Pain is the promi nent symptom, with numbness and weakness less common. Phys ical examination will re veal a positive SLR tes t re s ult. If the pain persists longer than 1 month consider MRI. Urgent neuroimagin g is indicated if neuro logic deficits , u rin:-uy retention , saddle anes thesia are presen t, 0 r if neoplas m or e pidural abcess are suspect~~.
Cauda equina sy."" t .¥o me
Compression o f the S 1 nerve root produces constant back p ai n with saddl e distribution anesthesia (buttock a nd medial and poste rior thighs) , fecal incontine nce, bladder
dysfunction, motor weakness of the Jower limbs, and radiculopathy. The patient may limp and guard lumbar s pine movement, will not be able to heel walk or toe walk, and w ill have abnormal or asymmetrical knee and an kle DTRs. The SLR test result wilJ be posi tive. This syndrome is a surgical emergency.
Nonspecific Back Problems
Sciatica
The most common cause of sciatica radicu lopathy, or pain related to spinal nerve root involvement, is h erniated vertebral disk. His tory may disclose repetitive motion strain or strenuous lifting , tw1stmg, and bending. ALBP is associated with pain and burning that radiates along the lateral thigh, leg, and foot, sometimes associated with numbness along the dermatomal areas. SLR and sitting knee extension produce radicular pain below the knee at less than 60 degrees of limb eleva tion, and pain may be felt in the buttocks or posterior thigh. Bowel and bladder functions are normal.
Musculoskeletal strain (postural, overuse)
Back structures such as muscles and liga ments can become inflamed from overuse or strain. History often reveals no precipitating event fo r the onset of pain. Patients may re port that pain is alleviated by rest, especially in the supine position with hips and knees flexed, and by the application of heat or cold. Pain is aggravated by sitting, walking, stand ing, and with certain motions. On physical examination, palpation will localize the pain, and muscle spasms may be felt. Range of motion of the spine will increase the pain, especially with forward flexion. Neurologic examination shows no abnormalities.
Spondylolisthesis
P a in can be the result of di s ruption of the vertebral s pinous proc ess, where the disrup tion results in subluxation of the vertebral body onto adjacent structures. This usually occurs between L5 and S 1. Pain is usually chronic. Examination of the spme m ay
Chapter 24 • Low Back Pain (Acute)
disclose a palpable, prominent spinous pro cess. Forward flexion may be limited.
Ankylosing spondylitis
Ankylosing spondylitis is a systemic inflam matory condition of the vertebral column and sacroiliac joints. Peak incidence is in people 20 to 30 years old; males are most often affected. Patients report chronic LBP, which is worse on morning rising and lessens as the day progresses. Examination shows an exces sive thoracic kyphosis and rounding of the posterior thoracic spine with forward flexion of the head, neck, and lower back. About 30o/o of patients will have arthritis of other joints. Radiographs may reveal fusion of vertebrae, and ESR is elevated.
Spinal stenosis
Spinal stenosis is a bony encroachment on the nerve roots of the lumbar spine and is the most common cause of ALBP in adults older than 50 years. Patients report ALBP associated with lumbosacral radiculopathy, pain with walking or standing, and pain relief with sitting or for ward flexion ofthe spine. Neurogenic (pseudo) claudication pain of the lower extremities is made worse with prolonged standing, walking, bending, or hyperextending the back.
Scheuermann disease
Adolescents develop this disease as a result of anterior disk protrusion, causing wedging of the thoracic vertebrae and exaggeration of the normal posterior convex curvature of the thoracic spine. The cause is unknown but may develop from excessive lifting or spinal flexion. The patient reports mild to moderate pain, worsening toward the end of the day or after physical activity but relieved by res t. Physical examination demonstrates an in crease in thoracic kyphos is on lateral view. made sharper by forward bending.
Osteoporosis
Osteoporosis is loss of mineralized bone mass that can result in a compression fracture of the
vertebral body, usually occurring in the tho racic area. Back pain is often chronic and poorly localized. Multiple compression frac. tures may produce dorsal kyphosis and cervj. cal lordosis. Estrogen deficiency, through menopause or medications, is a risk factor. It is also common in people older than 70 years who have age-related reduction in vitamin D synthesis. Osteoporosis can also be secondary to endocrine imbalance (e.g. , hyperthyroid ism), organ disease, drugs (e.g. , corticoste roids), or excessive intake of alcohol. The Fracture Risk Assessment Tool (FRAXR) is a web-based algorithm used to calculate the 10-year probability of hip and femur fracture based on clinical risk factors and BMD results .
Vertebral compression fracture
Causes of vertebral c01npression fractures are trauma, osteoporosis , and systemic disease. In older adults, compre s sion fractures secondary to osteoporosis m a y b e without symptoms. Patients may report p ain, loss of sensation, or loss of continence a fter a trauma. A history of cancer may indicate a:netastasis. Radiograph will detect a fracture.
Nonspinal Causes
Aortic aneurysm (dissecting)
Sudden onset of severe low or middle back pain that is not alleviated by rest in people older than 30 years might suggest a dissecting aortic aneurysm. The patient may exhibit pallor, diaphoresis, and confusion. Pulses and b lood pressure measured on each upper <"'Xtre mity will be asymmetric. Emergency surgery is indicated.
{;llllstones
Gallbladder problems increase w ith age. A gallbladder attack often follows a fatty meal. Crampy right upper quadrant (RUQ) pain followin g a fatty meal is produced by spasms of the cystic duct that is obstructed with a stone. Ga llbladder pain radiates around the trunk to the right scapula. Position does not affect the pain. Patients report belching and
Attacks may increase in frequency-00 btoatte;~rity and cause nighttime wakening.
5 and . g an attack, palpation will show RUQ o:;;rness. Physical findings between at ce k may be normal, or there may be tender
5 taC to palpation of the RUQ on inspiration ;::~by sign) if the gallbladder is inflamed.
RUQ mass may be felt if the gallbladder AJ1 . . . obstrocted. Obstruction 1s an emergency tS • . surgical s1tuat10n.
Pyelonephritis
With pyelonephritis, the patient will appear ill and diaphoretic and may report nausea and vomiting, headache, and back or flank pain. The patient may have a fever. Severe lumbar tenderness will be found on fist percussion for costovertebral angle tenderness. Urinalysis will show cloudy, malodorous urine, and micros copy will show casts and cells (i.e., red blood cells, white blood cells, and epithelial cells).
Pleuritis
Inflammation of the pleural lining of the lungs often follows an upper respiratory tract infection. Pleuritic pain is sharp, worsens on inspiration or with coughing, and is lessened by lying on the affected side. Physical exami nation ofthe lungs may be normal, or crackles and bronchial breath sounds will be heard on auscultation. A chest radiograph wiU provide information on the condition of the lungs.
~ .. ..,· .
Chapter 24 • Low Back Pain (Acute)
Pelvic inflammatory disease
The symptoms of PID depend on the extent of infection. In£ection usually begins in the lower urinary tract or cervix and spreads to the endometrium, Fallopian tubes, and perito neum. The sexually active patient may have mild to moderate dull, aching, lower abdomi nal, pelvic, or possibly back pain. The patient will report tenderness during cervical motion, uterine motion, or palpation of the adnexa. History may be positive for sexually transmit ted infections (usually Neisseria gonorrhoeae or Chlamydia trachomatis), vaginal symp toms, or use of an intrauterine device for contraception.
Psychogenic Causes
Psychologic back pain
A careful history is needed to gain insight into the psychosocial and economic issues surrounding report of back pain. The patient may have a history of recent life stressors, be involved in a legal injury or workers' com pensation action, or have a his tory of depres sion or alcohol abuse. The clinician should be aware of exaggerated signs of pain, such as moaning, grimacing, or overreacting. A ma lingerer pretends to suffer but, when dis tracted, will show inconsistent and variable results on examination such as SLR, or will describe radiation of pain inconsistent with dermatome distribution.
. ' DIFFERENTl~l]f _.1AGNOSIS OF Co111111on Causes ofAcute Lo1v Back - '> .... .;!!;" . ... ...
Pa111 .;1f. ·-::.! .·· ,... J··
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
POTENTIALLY SERIUUS CAUSES Spina l fracture Trauma to spine or back; Palpable tenderness Considered an
pain is felt near site of over site of fracture emergency; 1im injury mobilize patient
and transport for radiographs
Tumor History of cancer; Weight loss, fever, ESR; bone scan; progressive pain is tenderness near MRI unremitting; occurs at tumor night and at rest
Continued
Chapter 24 • Low Back Pain (Acute)
:: DIFFERENTIAL DIAGNOSIS OF Co111111011 Causes of.Acute i#jw Back Pt1i11- co11t ·,1 .-_. ~
·-' '
I II
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Osteoblastoma Neck or back pain not relieved by aspirin; occurs in older adoles cents and young adu lts
Osteoid osteoma Occurs primarily in ado lescents ; rare in pa tients older than age 40 yr; well - loca l ized pain that may be more severe at night and relieved by aspirin or other prostaglandin inhibitors
Infection H istory of infection, (vertebra l invasive procedure; osteomyel itis) continuous, dull back
pain ; chronic back pain D iski t is Pain aggravated by move
ment; more common i n chi ldren
Herniated disk LBP radiating down the buttock to below the knee , symptoms present < 1 mo
Cauda equina Constant pain in a syndrome sadd le distribution;
urinary retent ion, fec al incontinence, radiculopathy
NONSPECIFIC BACK PROBLEMS Sciatica Acute back pain with
radiculopathy; history of strain or trauma, rel ief with sitting
Musc u !oskeletal Pain in back, buttock s; strain history of new activity
or exertion; relief of pain with sitting
Localized tenderness; Plain film shows an may have scol iosis expansive osteo with muscle pain lytic lesion sur-
rounded by th in peripheral rim of bone; bone scan; CT scan
Painfu l , well-localized Bone scan scoliosis may be present
Acute onset with fever, ESR; blood culture; diaphoresis; tender- bone biopsy; CT ness over affected scan; MRI disk; positive S LR
Tenderness over ESR ; CT aff ected disk
Positive S LR MRI
Positive SLR, abnormal MR I , s urgical DTRs, motor weakness emergency
Paravertebra l tender- MRI ness and spasm; positi ve SLR; sitting knee extension, sensory findings
Paravertebral tender- None ness, scoliosis, or l oss of lumbar lordosis; no neurolog- ica l sign s
Chapter 24 • Low Back Pain (Acute)
-~-' ~ DIFFERENTIAL DIAGNOSIS.~9F Co111111011 Cctuses ofAcute Lou' Blick '· Pai11--co11t •d
HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIESCONDITION
spondylol isthesis
Ankylosing spondylitis
Spinal stenosis
Scheuermann disease
Osteoporosis
Vertebral compression fracture
NONSPINAL CAUSES Aortic aneurysm
Young person in a sport that demands rapid movement between hyperflexion and hyperextension or re quires excess loading in hyperextension
Younger than age 40 yr: insidious onset; pro gressive morning back pain relieved with exercise
Pain worse throughout day; aggravated by standing, relieved by rest; pseudoclaudication
Affects mostly adolescent males; mild to moder ately severe pain, worse at end of day, re Ii eved by rest
Chronic, p oorly localized bac k pain ; postmeno pau sa i ; s l ight b uild ; history of inactivity or endocrine disorder
Pain, loss of sensation, incontinence; trauma to the spine; history of ca n cer, osteoporosis
Severe , acute-onset pain not related to activity or movement; in c reased risk older tha n age 30 yr; pallor, diaphoresis, anxiety, confusion
No neurological signs; pain localized to low back, just below level of i I iac crest; tight hamstrings
Painful sacroiliac joints, reduced spine mobil ity; may have uveitis
Signs of osteoarthritis of joints; may have neurological s igns
N o rmal examination; may show an exag gerated thoracic kyphosis that is fi xed in attempted hyperextension
Palpable tenderness over area of compres s ion frac ture; kypho sis or lordosis; loss of heig ht
Palpable tenderness over fracture, obser vation of s pine deformity
Intact aneurysm will be a visible pulsatile midline upper quad rant abdominal mass; in a dissected aneu rysm, upper extremity pulse and pulse pres s ures are asymmetric; posterior thoracic pain may be felt
Lumbar s pine radiographs
ESR ; spinal radiographs
MRI
Thoracic spi ne radiographs
Bone densitometry; FRAXR score; sp i nal rad iograph to assess fracture
Radiograph to detect fracture
Emergency surgical referral
Continued
Chapter 24 • Low Back Pain (Acute)
'"" .,..._. :;j DIFFERENTIAL DIAGNOSIS OF Co111111011 Cttu.•ies <~f'AcuteJ~o•v Back
Pai11-co11t'tl "·:.. ,f .1w;-·
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Gallstones Increased incidence with Normal physical exami Su rgical referral age; steady, intense pain nation or positive in RUQ with radiation to Murphy sign on pal right scapu la or shoul pation of abdomen der; belching, bloating, fatty food intolerance
Pyelonephritis Ill-appearing; sweating, Fever; cloudy, malodor Urinalysis; urine nausea, back or flank ous urine; CVA culture pain, headache tenderness on
percussion Pleuritis History of recent URI; Normal examination or PPD; chest
pleuritic pain crackles and bron radiograph chial breath sounds
Pelvic Sexually active female; low Cervical and uterine Gonorrhea, inflammatory back and abdominal motion tenderness, Chlamyd ia disease pain; history of urinary adnexal tenderness; cultures; ESR
or vaginal symptoms, cervic itis, fever sexually transmitted disease, IUD, multiple sex partners
PSYCHOGENIC CAUSES Psychological History of psychosocial Exaggerated or incon None
back pain stressors, depression, sistent reactions to exaggerated expres testing; normal sions of pain examination
CT, computed tomography; CVA, costovertebral angle; DTRs, deep tendon reflexes; EMG, electromyography; ESR, erythrocyte sedimentation rate; IUD, intrauterine device; LBP, lower back pain; MRI, magnetic resonance imaging; PPD, purified protein derivative; RUQ, right upper quadrant; SLR, straight leg raising; URI, upper respiratory tract infection.
