Acute Low Back Pain

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Biomedically there are three aims in the approach to acute low back pain. The first is to determine whether the presenting complaint is in fact low back pain, and whether it is acute or not. The second aim is to determine whether any referred pain is somatic referred pain or radicular pain. The third aim is to identify any serious conditions.

Definitions

Main article: Low Back Pain Definitions

IASP Definitions

Topography

Starting with the wrong definition of low back pain can lead to the wrong diagnosis, and so it is important to be clear here. The IASP taxonomy categorises low back pain into lumbar spinal pain and sacral spinal pain. There is also an overlapping definition called lumbosacral pain. These three categories constitute the colloquial term "low back pain."

Lumbar spinal pain is pain in a region bounded superiorly by an imaginary transverse line through the tip T12, inferiorly by an imaginary transverse line through the tip of S1, and laterally by vertical lines tangential to the lateral borders of the lumbar erectores spinae.

Sacral Spinal Pain is pain in a region bounded superiorly by an imaginary transverse line through the tip of S1, inferiorly by an imaginary transverse line through the posterior sacrococcygeal joints, and laterally by imaginary lines passing through the posterior superior and posterior inferior iliac spines."

Lumbosacral Pain is pain perceived as arising from a region encompassing or centred over the lower third of the lumbar region as described above and the upper third of the sacral region as described above.

Acuity

Acute pain is pain that has been present for no longer than 12 weeks. Subacute pain is pain present for longer than 5 or 7 weeks but less than 12 weeks. The management differs depending on the acuity.

Referred Pain

Main article: Low_Back_Pain_Definitions#Referred_Pain

Referred pain is "pain perceived as arising or occurring in a region of the body innervated by nerves or branches of nerves other than those that innervate the actual source of pain"

Visceral referred pain is referred pain where the source lies in an organ or blood vessel of the body. With low back pain, the uterus and abdominal aorta are important considerations. Other viscera with higher segmental supply may cause back pain such as pancreatitis, but this may be due to irritation of the posterior abdominal wall, in which case the pain is not truly referred in nature.

Somatic referred pain is referred pain where the source originates in a tissue or structure of the body wall or limbs. A number of structures in the lumbar spine are capable of nociception including the lumbar zygapophysial joints, intervertebral discs, sacroiliac joints, and more.

Radicular pain is a subset of neuropathic pain, and refers to pain that is evoked with stimulation of the nerve roots or dorsal root ganglion of a spinal nerve. In radicular pain, the pain is felt in the peripheral innervation of the affected nerve.

Aetiology

Unlike with chronic low back pain there is little research on the aetiology of acute low back pain. No patho-anatomic diagnosis of low back pain can be made clinically without the use of special investigations (e.g. discography, medial branch blocks, sacroiliac joint blocks). Special investigations are not appropriate for acute low back pain, and are reserved for chronic low back pain. Furthermore medical imaging is not able to identify sources of pain other than fractures.

The most important part of the assessment in acute low back pain is evaluating for red flag conditions. Fractures occur between 1-4% of cases, malignancy in 0.2%, and infection in 0.01%. Other conditions that are important to detect are cauda equina, and spondyloarthropathies.

In the acute setting in the absence of red flags, the diagnosis is simply "acute low back pain."

Prognosis

Main article: Prognosis of Low Back Pain

It is sometimes stated in guidelines that most patients with acute low back pain make an excellent recovery. The evidence is in fact quite conflicting, with markedly different findings across different studies. Overall the treating doctor can relay optimism, but be guarded about prognosis. The data on recurrence rates are also conflicting.

A systematic review of 11 studies performed in the US, Australia and Europe on patients with non-specific back pain found that recovery occurred in 33% of patients at 3 months, and by 1 year 65% still had pain. In studies that used total absence of pain as a criterion, 71% still had pain at 12 months. In studies that had a less stringent criteria, 57% still had pain at 12 months.

Prognostic risk factors are broadly categorised into biological and psychosocial. Predictors of recurrence are often variable across studies, but generally include

• Sociodemographic: female gender, obesity, poor educational level
• Current History: previous episodes, duration of episode, days to seek care, pain and disability levels, leg pain
• General Health: Smoking, habitual physical activity, perceived health, use of medications
• Psychosocial: Perceived risk of recurrence, depression, anxiety, fear-avoidance behaviour, overprotective family or lack of support.
• Work-related: Involvement in heavy lifting or awkward positions, job satisfaction, compensable case
• Others: MRI findings, qualification of practitioner.

The psychosocial and occupational barriers are termed "yellow flags".

Assessment and Management Algorithm

Because a specific tissue diagnosis cannot be made with any validity in the vast majority of cases of acute low back pain, the management is not based on finding and treating a particular cause.

The Musculoskeletal algorithm starts with Triage which refers to confirming the taxonomy and looking for serious causes of pain. After Management is Concern which refers to seeing if the patient is responding. Vigilance is rechecking for red flag conditions at subsequent encounters. Reinforce is reinforcing previous interventions, and Supplement is applying adjunct measures.

Assessment

Triage begins with checking that the patient does have back pain and that it is likely to be a benign condition arising from the spine, rather than another serious cause. Red flags have poor predictive value, but this is not their value, they are simply an alerting feature. It lets the doctor know to consider exploring the possibility of serious conditions further.

Pain History

A pain history should be undertaken. Some advocate the traditional systematic approach but this has not been proven to improve diagnostic accuracy and many of the questions have unproven or non-existent validity. This approach is also usually not viable in primary care, and the doctor will make a judgement as to the most pertinent questions to ask while carefully safety netting.

The traditional systematic approach includes questioning around presenting complaint, length of illness, site, location and extent of spread, quality, severity, frequency, duration, time of onset, mode of onset, precipitating factors, aggravating factors, relieving factors, and associated fevers.

The presenting complaint and site are around confirming that they do indeed have back pain as opposed to loin pain or gluteal pain for example. The length of illness is around establishing if it is acute or chronic.

The location and extent of spread and quality are about distinguishing somatic referred from radicular pain. Incorrectly distinguishing radicular pain from somatic referred pain is a common pitfall in diagnosis and with incorrect diagnosis this frequently leads to incorrect treatment.

The patient should be asked where their "main" or "worst" pain is, or where they feel the pain most often and most consistently. Reciprocally they can be asked where they feel the pain only sometimes.

Patients may have a combination of somatic and referred pain from the same process e.g. a herniated disc causing somatic pain from irritation of the dura of the nerve root plus radicular pain from irritation of the nerve root itself.

Somatic Referred vs Radicular Pain

	Somatic Referred	Radicular
Pain quality	Dull, deep ache, or pressure-like, perhaps like an expanding pressure	Shooting, lancinating, or electric-shocks
Relation to back pain	Referred pain is always concurrent with back pain. If the back pain ceases then so does the referred pain. If the back pain flares then so does the leg pain intensity and spatial spread.	Not always concurrent with back pain.
Distribution	Anywhere in the lower limb, fixed in location, commonly in the buttock or proximal thigh. Spread of pain distal to the knee can occur when severe even to the foot, and it can skip regions such as the thigh. It can feel like an expanding pressure into the lower limb, but remains in location once established without traveling. It can wax and wane, but does so in the same location.	Entire length of lower limb, but below knee > above knee. In mild cases the pain may be restricted proximally.
Pattern	Felt in a wide area, with difficult to perceive boundaries, often demonstrated with an open hand rather than pointing finger. The centres in contrast can be confidently indicated.	Travels along a narrow band no more than 5-8 cm wide in a quasi-segmental fashion but not related to dermatomes (dynatomal).
Depth	Deep only, lacks any cutaneous quality	Deep as well as superficial
Neurological signs	Not characteristic	Favours radicular pain, but not required.
Neuroanatomical basis	Discharge of the peripheral nerve endings of Aδ and C fibres from the lower back converge onto second order neurons in the dorsal horn that also receive input from from the lower limb, and so the frontal lobe has no way of knowing where the pain came from.	Heterotopic discharge of Aδ, Aβ, and C fibres through stimulation of a dorsal root or dorsal root ganglion of a spinal nerve, typically in the presence of inflammation, with pain being felt in the peripheral innervation of the affected nerve

The severity of back pain does not correlate with the severity of the disease process but can be recorded as a baseline VAS. The frequency and duration relates to how it waxes and wanes and how long for, and is usually related to aggravating factors rather than the disease process. They are not of diagnostic value. The time of onset is about whether they have morning stiffness. The sensitivity is moderate but specificity is poor for spondyloarthropathies.

The mode of onset is how it started such as spontaneously or with an injury. Spontaneous pain with an explosive onset is anecdotally concerning. Otherwise the circumstances of onset are not usually helpful in a diagnostic or prognostic sense. Possibly twisting injuries may be a risk for torsion injuries, but a patho-anatomical prediction can't be made. Likewise sudden axial loading may be a risk for a compression injury. Extension injuries in sportspeople may be the exception for relevance as this indicate a pars interarticularis fracture.

Precipitating factors are activities that bring on pain and aren't helpful diagnostically. Aggravating factors are activities that aggravate the pain, and the absence of any mechanical aggravating factors is of concern. Relieving factors are those that improve the pain such as medications, wheat bags, etc. Pain that isn't relieved by rest may raise concern for a serious disorder.

Associated features may be the most helpful category of enquiry in terms of identifying serious causes, and is discussed as part of the red flags section below.

Red Flags

Red flag conditions are rare, and so the pre-test probability is in favour of the pain being benign. Red flag conditions are suspected primarily based on the history and examination. Identifying certain conditions makes no difference to the outcome, while in other cases it does.

A red flag checklist can be used. There are case reports of red flag conditions being missed, and that they may have been identified earlier if the correct questions were asked. Red flags should be checked for at each visit (i.e. vigilance).

Red Flags

• History of: Trauma, sports injury, fever, night sweats, recent surgery, catheterisation, venipuncture, illicit drug use, weight loss, cancer, occupational exposure, hobby exposure, overseas travel, pain severe worsening or unremitting especially at night
• Cardiovascular: Risk factors
• Respiratory: Cough in a smoker or ex-smoker
• Gentio-urinary: Infection, haematuria, retention, stream problems
• Gynaecological: abnormal uterine bleeding, dysmenorrhoea
• Haematological
• Endocrine: Diabetes, corticosteroids, parathyroid
• Musculoskeletal: pain elsewhere
• Neurologic: symptoms/signs including for cauda equina compression
• Skin: Infection, rashes
• Gastrointestinal: Diarrhoea, inflammatory bowel disease
• Demographic: Aged over 50 years with first episode, especially age over 65 years

Cancer:, the pre-test probability is low at less than 0.7%. Most patients who have cancer as a cause are elderly. The single strongest predictor is a past history of cancer. Other indicators of malignancy are lack of relief with bed rest, unexplained weight loss, failure to improve with therapy, and prolonged pain. Cough in a smoker or ex-smoker is a concern for spinal metastases. Myeloma may not be evident on history. Negative predictors are age less than 50, no past history of cancer, no weight loss, and no failure to improve with therapy. With a combination of the above, cancer is extremely unlikely.

Fracture:, major trauma is a risk. Minor trauma is only a risk if it is associated with osteoporosis, older age (>50), and/or history of prolonged corticosteroid use. In sports people pars interarticularis fractures should be considered.

Infection:, symptoms are often subtle, but may include malaise and fever. The risk factors are mainly those that make the individual susceptible such as penetrating injuries, or underlying conditions. Exotic infections are more likely with occupational exposure, certain hobbies, or recent travel.

Spondyloarthropathy: The earliest signs are morning stiffness, slow onset at age less than 30, and improvement with exercise. A history of psoriasis and inflammatory bowel disease are also clues. A combination of 4 out of 5 of morning stiffness, improvement with exercise, onset under 40, slow onset, and duration > 3 months has a +LR of 6.3, and -LR of 17. Generally ankylosing spondylitis is impossible to diagnosis early in the evolution and plain films do not generally detect changes in early disease. Note, pain elsewhere is also a clue for a systemic rheumatology conditions.

Other: Hyperparathyroidism and Paget's disease are occult causes of spinal pain. There are usually no clues on history.

Cardiovascular risk factors alert for possible aortic aneurysm.

Neurological features should be assessed along with any spinal pain, along with symptoms of cauda equina compression.

History of a urinary tract infection, haematuria, and urinary retention should lead to assessment of the renal tract.

Psychological and Social History

The aim of the psychological and social history is to identify so called "yellow flags."

An important psychological feature that has relevance is fear. Fearful patients are scared of underlying serious conditions, scared of making it worse, and scared of the prognosis. Fears should be managed if identified as they can negatively impact their rehabilitation. Anxiety and depression are also important.

The social history should include enquiring about their home situation, social supports, occupation, smoking history, alcohol history, relationships, and hobbies.

Physical Examination

Main article: Lumbar Spine Examination

The physical examination of the lumbar spine in general lacks reliability and validity. In short, it does not provide a diagnosis of acute low back pain. However, there are three main reason for doing a physical examination.

1. The first reason is that patients expect it, and doing it shows interest and caring.
2. The second reason is that if no signs of somatic dysfunction are found in the spine, then this could indicate a serious underlying visceral or vascular condition. However, due to visceral referred pain, patients with visceral pathology can still have somatic segmental dysfunction. Therefore an abdominal and vascular examination is still warranted in those at increased risk.
3. The third reason is that the doctor can provide positive reinforcement (e.g. celebrating normal findings) with the view of reducing patient fear.

The lumbar spine exam involvs inspection, palpation, and movement testing.

• Inspection: posture standing and sitting (scoliosis, kyphosis, loss of lordosis), dynamic posture (antalgic gait), deformities, scars, puncture marks, swelling. The reliability reported in studies has varied. The validity is unknown.
• Palpation: altered sensitivity (hypoesthesia, hyperesthesia), tenderness and its relationship to bony landmarks, and whether localised or diffuse. The reliability is excellent for tenderness somewhere in the lumbar spine (kappa 1.0), but when the location is specified the agreement is variable. Tenderness over the iliac crest superomedial to the PSIS is good (kappa 0.66), but the validity is unknown.
• Movement testing: active, passive, and accessory movement testing. Active and passive ranges are tested in flexion and extension, side bending, and rotation. Quadrant tested can also be done (e.g. extension with rotation). The reliability is fair to moderate, but the validity is unknown.

There are a variety of other tests. For the McKenzie assessment, the reliability is variable depending on the study, and the validity in acute low back pain is unknown, and only modest predictive value in chronic low back pain. Tests of the sacroiliac joint are reliable but their validity in acute low back pain is unknown. In chronic low back pain they have moderate validity.

A neurological examination is not required in the absence of neurological symptoms. If a patient has weakness, numbness, or radicular pain then certainly it is warranted, however the indication is the neurological symptoms, not the back pain. Neurological signs don't present with back pain as the only symptom.

A neurological examination can however be done with the goal of "appearing thorough." In that case a screening examination is sufficient. The L5 and S1 myotomes can be assessed quickly by having the patient walk on their heels and toes. Sensation can be assessed quickly with light touch. The reliability is good (kappa > 0.6). Reflex testing isn't needed in the absence of neurological symptoms but can be useful for positive reinforcement to the patient.

An abdominal examination and vascular examination are important for assessing for visceral (e.g. masses) and vascular (abdominal aortic aneurysm) disorders.

The demeanor of the patient can be helpful in identifying serious causes. Some patients with conditions like discitis or cancer can just "look unwell," with a serious and quietly guarded presentation. The aphorism is beware the quiet patient with severe pain.

It is important to explain what you are doing during the examination, i.e. what is being done and what is found. Give the patient positive feedback when positive findings are found. For example when testing the reflexes explain that a good reflex means that there is no blockage of signal. If they move well tell them. If their back muscles seem strong again tell them that their back seems strong and that their muscles are in good shape.

Investigations

See also: Lumbar Spine Radiographs, Lumbar Spine MRI

If a red flag condition is suspected then appropriate investigations should be done. Such investigations are not recommended as part of the routine assessment of low back pain, as they are not designed to investigate the cause of back pain. They also aren't screening tests in the absence of concern.

Appropriate Investigations for Different Conditions

Category	Clinical Features	Specific conditions	Investigations
Simple low back pain	No risk factors	N/A	Nil. Reassess after 4 to 6 weeks if no improvement
Primary tumours (rare, 0.04% of all tumours)		myeloma	Myeloma screen
		bone and cartilage tumours	Imaging
Secondary tumours (0.7%)	History of cancer, age greater than 50, failure to improve, weight loss, pain not relieved by rest	Prostate	Calcium, ALP, PSA, ESR and/or CRP, imaging
		Breast, lung, thyroid, kidney, gastrointestinal, melanoma	Plain radiography, ESR and/or CRP. If radiograph normal but elevated markers then MRI.
Infection	fever, sweating, immunosupression, dialysis, IVDU, invasive procedure, trauma to skin or mucous membrane, diabetes, alcoholism	Osteomyelitis, epidural abscess	MRI if moderate to high risk. ESR and/or CRP if low risk, with MRI if elevated.
Fracture	Significant trauma	Vertebral compression fracture	Plain radiograph
	Mild trauma in the elderly or history or risk factors for osteoporosis, elderly	Vertebral compression fracture	Plain radiograph
	Sporting activity involving extension, rotation, or both.	Stress fracture	Bone scan or MRI
Spondyloarthropathy (0.3 - 0.9%)		Ankylosing spondylitis	ESR and/or CRP
Metabolic bone disease		Paget's disease, Hyperparathyroidism	Calcium
Visceral disease	Smoking, hypertension, palpable mass	Aortic aneurysm	Abdominal exam, ultrasound (e.g. bedside)
		Retroperitoneal disease	Abdominal exam, ultrasound (e.g. bedside)
		Pelvic disease	Pelvic examination, rectal examination
Modified from Bogduk et al. Management of Acute and Chronic Low Back Pain. Elsevier 2002.

In other cases imaging is not indicated. Patients often have misconceptions about the diagnostic validity and need for lumbar spine radiographs. They may incorrectly think that radiographs will show the problem, that a normal radiograph excludes serious problems, and that they are completely safe. Careful communication is required around these misconceptions.

A controlled study found that careful communication only moderately reduced these misconceptions around radiographs but there were no differences in patient satisfaction. Also one study has shown no difference to outcome, while another found worse outcomes at 3 months.

A randomised study comparing early MRI or CT versus delayed imaging until clinical need found no different in outcome.

See Lemmers et al for a systematic review on the costs, healthcare utilisation, and absence from work associated with spinal imaging.

Explanation

See also: Good Back Consultation