Dr. RAJENDRAN’S INSTITUTE OF MEDICAL EDUCATION 1

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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
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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
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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
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4) How will you determine the likelihood of serious illness?
History
Rapidly obtain a targeted history to …………….
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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
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