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Acute Low Back Pain
Aka: Acute Low Back Pain, Musculoskeletal Low Back Pain, Mechanical Low Back Pain, Low Back Pain, Lumbago
- See Also
- Lumbar Spine Anatomy
- Low Back Pain History
- Low Back Pain Red Flags
- Low Back Exam
- Differential Diagnosis of Low Back Pain
- Lumbar Disc Disease
- Low Back Pain Management
- Low Back Imaging
- Rheumatologic Conditions affecting the Low Back
- Low Back Pain in Children
- Low Back Pain in Teen Athletes
- Definition
- Low Back Pain
- Pain distribution between the costal angles and the gluteal folds
- Mechanical Low Back Pain
- Back pain with origin in the spine, intervertebral discs and surrounding soft tissue
- Includes strains, disc Herniation, Spondylosis, Spondylolisthesis, Spondylolysis, compression Fractures
- Duration
- Acute: Less than 4 weeks
- Subacute: 4 to 12 weeks
- Chronic: More than 12 weeks
- Radiation
- Sciatica with pain radiating down one or both legs
- Epidemiology
- Age of onset: Typically first episode occurs between ages 20-40 years old
- Chronic Low Back Pain affects 23% of the population worldwide
- Frequent, severe Low Back Pain Prevalence occurs in 8% or 11.8 of 145 Million Employed Adults (U.S., 2015)
- Ages 18-29: 5.9% (1.99 Million)
- Ages 30-44: 7.9% (3.74 Million)
- Ages 45-64: 9.7% (5.52 Million)
- Age >65: 8.7% (0.63 Million)
- CDC Low Back Pain
- https://wwwn.cdc.gov/Niosh-whc/chart/ohs-lowback/illness?OU=FS_PAINLB&T=A&V=R
- History
- See Low Back Pain History
- See Serious Low Back Symptoms (Low Back Pain Red Flags)
- Exam
- Back should be exposed (e.g. in gown) to allow for adequate palpation and visualization
- See Low Back Exam
- See Lumbar Spine Anatomy
- Differential Diagnosis
- Mechanical Causes (90%)
- Lumbosacral strain (70%)
- Isolated Trauma or repetitive overuse
- Lumbar Spondylosis (10%)
- Chronic disc degeneration and secondary foraminal narrowing in over age 40 years old
- Lumbar Disc Herniation (5%)
- Occurs at L4-5 or L5-S1 in 90-95% of cases
- Spondylolysis (<5%)
- Young athletes with frequent lumbar hyperextension (e.g. gymnastics, football)
- Vertebral Compression Fracture (4%)
- Vertebral Fracture and collapse, typically due to Osteoporosis, and most commonly at L1 and L4
- Spondylolisthesis (3-4%)
- Vertebral slippage anteriorly, at L5 in 90% of cases, with Leg Pain, Paresthesias and weakness
- Lumbar Spinal Stenosis (3%)
- Narrowing of lumbar spinal canal with back pain and leg numbness, weakness better with rest
- Non-mechanical Causes
- See Low Back Pain Red Flags
- Spondyloarthropathy
- Ankylosing Spondylitis
- Reiter's Syndrome
- Spinal Infection
- Osteoporosis
- Cancer
- Referred visceral pain
- Abdominal Aortic Aneurysm
- Pancreatic Cancer
- Genitourinary cancer
- Lumbar Stenosis
- Cauda Equina Syndrome
- Evaluation: Acute Low Back Pain without radicular symptoms (93%)
- Simple Musculoskeletal Low Back Pain
- Indicated if no Low Back Pain Red Flags
- Conservative therapy for 6 weeks
- Complicated Low Back Pain
- Indications: Risk of cancer or infection
- See Low Back Pain Red Flags
- Lab work
- Complete Blood Count
- Urinalysis
- Erythrocyte Sedimentation Rate (ESR)
- Highly suggestive if ESR >50 mm per hour
- Prostate Specific Antigen (PSA)
- Consider in men over age 50
- Initial Imaging: L-Spine XRay Indications
- Risk factors for non-mechanical cause (see above)
- Erythrocyte Sedimentation Rate (ESR) >20 mm/hour
- Low Back Pain Red Flags
- Additional management if indicated by XRay or ESR
- Consider MRI Spine (preferred imaging)
- Consider Bone Scan
- Consider orthopedic Consultation
- Evaluation: Acute Low Back Pain with radiculopathy past the knee (4%)
- See Lumbar Disc Herniation
- Conservative management in 99% of cases
- Indicated if no indications for urgent evaluation
- CT or MRI Spine if not improving by 6 weeks
- Urgent evaluation in 1% of cases
- Indications
- Cauda Equina Syndrome
- Rapid progression of neurologic deficit
- Urinary Retention
- Saddle Anesthesia
- Bilateral neurologic deficit
- Protocol
- Immediate Consultation for possible discectomy
- MRI Lumbosacral Spine
- Evaluation: Acute Low Back Pain suggestive of Lumbar Stenosis (3%)
- Indication
- Seen in older patients
- Leg and back pain relieved when sitting
- Conservative management in most cases
- Evaluation for more significant stenosis
- Indications
- Failed conservative therapy
- Intolerable symptoms
- Neurologic deficit
- Protocol
- CT or MRI Spine
- Consultation for possible laminectomy
- Evaluation: Acute Low Back Pain Suggestive of Vertebral Fracture
- Obtain L-Spine XRay
- Negative XRay and persistent symptoms >10 days
- Consider bone scan or CT Spine
- Consider orthopedic or spine Consultation
- Evaluation: Acute Low Back Pain with Cancer History
- New or worse over prior 1-3 days radiculopathy Incontinence, weakness or sensory change and a cancer history
- Risk of tumor with cord compression
- Dexamethasone 10 mg orally or IV AND
- Emergent MRI (typically from Cervical Spine through Lumbar Spine)
- Stable low back symptoms >1 week without progression and a cancer history
- Consider Dexamethasone
- Lumbar MRI (typically from Cervical Spine through Lumbar Spine) within 24 hours
- Low Back Pain with normal Neurologic Exam, no Incontinence and a cancer history
- Routine repeat evaluation with primary provider
- Consider Lumbar MRI
- References
- Della-Giustina and Spangler in Herbert (2013) EM:Rap 13(11): 6
- Imaging
- See Low Back Imaging
- See Low Back Pain Red Flags
- Lumbar Spine XRay Indications
- Consider in age over 50 years or under 18 years old, or acute Lumbar Spine Trauma
- Vertebral Fracture
- Spondylolisthesis
- Lumbar Spine CT Indications
- Spinal Trauma
- Vertebral Fracture
- Vertebral dislocation
- Spondylolisthesis
- Lumbar Spine MRI Indications
- Lumbosacral Radiculopathy >6 weeks despite conservative management
- Spinal Epidural Abscess (Spinal Osteomyelitis)
- Spinal Cord Tumor
- Cauda Equina Syndrome (or spinal stenosis)
- Nontraumatic vascular injuries of the spine
- Course
- Acute Low Back Pain (95%)
- Resolution in 1 week: 50%
- Resolution in 8 weeks: 90%
- Recurrent Low Back Pain
- Recurs in at least 25% of patients within 1-2 years
- Moderate to severe in at least a third of patients
- Chronic Low Back Pain (<5%)
- Management
- See Low Back Pain Management
- See Return to Work in Lumbar Back Pain
- References
- Arce (2001) Am Fam Physician 64(4):631-8 [PubMed]
- Atlas (2001) J Gen Intern Med 16:123 [PubMed]
- Bratton (1999) Am Fam Physician 60(8):2299-306 [PubMed]
- Bueff (1996) Prim Care 23:345-64 [PubMed]
- Jarvik (2002) Ann Intern Med 137:586-97 [PubMed]
- Joines (2001) J Gen Intern Med 16:14-23 [PubMed]
- Patel (2000) Am Fam Physician 61(6):1779-86 [PubMed]
- Rose-Innes (1998) Geriatrics 53:26-40 [PubMed]
- Swenson (1999) Neurol Clin 17:43-63 [PubMed]
- Will (2018) Am Fam Physician 98(7):421-8 [PubMed]