Back Pain

Article Author:
Vincent Casiano
Article Editor:
Nikhilesh De
Updated:
11/23/2019 3:25:24 PM
PubMed Link:
Back Pain

Introduction

Back pain is one of the most common causes for patients to seek emergency care. It has a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly it is mechanical or non-specific in nature. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. It is essential to be able to evaluate patients of all ages and understand the unique differences in the presentation in these different populations. Knowing the common red flags of back pain in both children and adults can guide the provider to appropriate evaluation and treatment.

Etiology

Back pain is a broad topic with many potential etiologies that are broken mainly in four major categories[1]

  • Mechanical: which is caused by the spine, intervertebral discs, or soft tissues
  • Inflammatory: which is caused primarily due to inflammatory spondyloarthropathies
  • Oncologic: Which is caused by lytic lesions to the spine, cancers of the marrow, or nerve compressive phenomena from adjacent space occupying lesions
  • Infectious: Infections of the spine, discs, epidural abscesses, or muscular/soft tissue abscesses

It is important to note, however, that many non-back-related disorders may result in pain that patients perceive in the back such as biliary colic, pneumonia, and obstructive or infectious renal disease. Therefore, it is prudent not to exclude these processes from your differential diagnosis while evaluating the patient.

Epidemiology

Back pain is widespread in the adult population. Some studies have shown that up to 23% of the world’s adults suffer from chronic low back pain. This population has also shown a one-year recurrence rate of 24% to 80%.[2][3] Some estimates of lifetime prevalence are as high as 84% in the adult population.[4]

However, the prevalence is much less apparent in the pediatric literature. One Scandinavian study demonstrated that the point prevalence of back pain was approximately 1% for 12-year-olds and 5% for 15-year-olds, with a cumulative incidence of 50% by age 18 for females and age 20 for males.[5] An extensive systematic review demonstrated an annual rate of adolescents suffering from back pain of 11.8% to 33%.[6]

History and Physical

A thorough history and physical exam are critical in the evaluation of the patient with back pain in both adult and pediatric populations.

The historical characteristics of the pain that require elucidation are very similar for the two populations. The mechanism of injury (if one is present), the intensity and the quality of pain, whether the pain radiates, what the alleviating and provoking factors for the pain are, and what treatments have been tried (and whether those treatments were effective) are all critical for the gathering a thorough history of present illness. It may also be helpful to assess what the impact on the patients daily living the pain has caused, such as work/school absenteeism, as useful clues for functional impairment. Past medical and family history (including the history of cancers or inflammatory conditions) and social history (including periods of injection drug use, exercise regimens, periods of exposure to tuberculosis) can also change the most likely working diagnosis

The physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the exam. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation and deep tendon reflex) assessments. Several provocative maneuvers are helpful for demonstrating or decreasing suspicion of different processes.

Straight leg raise (SLR): performed by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. Likelihood ratio (LR) of 2, negative likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for lumbar disk herniation with LR of 3.5 and NLR of 0.72.[7]

One leg hyperextension test/stork test: Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.[8]

Adam test: Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication for scoliosis.[8]

There are numerous other examination techniques; however, they have mixed evidence for inter-practitioner reliability and poor sensitivities or specificities.

Red flag historic or physical exam features that, when present, should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:

Adults[3][9][10][7]:

  • Cauda equina syndrome:
    • History: Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
    • Physical exam: Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
  • Fracture:
    • History: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
    • Physical exam: Contusions, abrasions, tenderness to palpation over spinous processes
  • Infection:
    • History: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
    • Physical exam: Fever, wound in the spinal region, localized pain, and tenderness
  • Malignancy:
    • History: History of metastatic cancer, unexplained weight loss
    • Physical exam: Focal tenderness to palpation in the setting of risk factors

Pediatric red flags are the same as adults with a few notable differences[11][12]:

  • Malignancy:
    • History: age less than 4 years, nighttime pain
  • Infectious:
    • History: age less than 4 years, nighttime pain, history of tuberculosis exposure
  • Inflammatory:
    • History: age less than 4 years, morning stiffness for greater than 30min, improving with activity or hot showers
  • Fracture:
    • History: activities with repetitive lumber hyperextension (sports such as cheerleading, gymnastics, wrestling, or football linemen)
    • Physical exam: Tenderness to palpation over spinous process, positive Stork test

Evaluation

While typically history and physical exam are sufficient for evaluation of back pain, the presence of red flags or pain that is protracted may require further investigation. Early imaging in the adult population correlates with worse outcomes and more invasive treatments without a commensurate improvement in outcomes.[13][14] Imaging for adults should be reserved for symptoms that last longer than six weeks with appropriate conservative management.[13] Protracted pain in children should have imaging; however, the definition of protracted has not been as clearly defined as it is in adults.

Anteroposterior and lateral plain films should be sufficient to evaluate for boney pathology, whereas MRI may be necessary to evaluate for soft tissue lesions, nerve root/cord compression from a bulging disc, malignancy, and inflammatory conditions of the spine and surrounding tissues.[15][16] Bone scans may demonstrate osteomyelitis, discitis and stress reactions, but remains inferior to MRI to evaluate these conditions.[17] In adolescents with MRI evidence of herniated disc, one may consider CT to confirm or rule out apophyseal ring separation as this occurs in 5.7% of these patients.[18]

In addition to imaging, one may consider laboratory evaluation if red flags are present. Rheumatologic assays such as HLA-B27, ANA, RF, and Lyme are typically not helpful in the evaluation due to their unspecificity.[19][20][21] Inflammatory markers such as CRP and ESR along with CBC and blood cultures may assist in the diagnosis of inflammatory, infectious, or malignant etiologies. The addition of LDH and Uric acid may assist in diagnosing a condition with rapid marrow turnover such as leukemia.[22]

Treatment / Management

There are various treatments for pain based on etiology, age, and chronicity of the back pain. The best evidence in adult back pain according to the "Noninvasive treatments for low back pain: current state of the evidence" clinician summary published by the Agency for Healthcare Research and Quality in 2016:

In Adults:

For radicular low back pain, nonpharmacologic interventions such as exercise, traction, and spinal manipulation have shown some benefits but have relatively weak levels of evidence to support it. NSAIDs has moderate evidence of benefit, however other pharmacologic interventions such as diazepam and systemic steroids do not seem to provide benefit. [AHRQ,  2016].

For non-radicular acute or subacute low back pain, acetaminophen appears to have weak evidence of no benefit. However, NSAIDs, heat, and muscle relaxants have moderate evidence for positive benefit. Massage has weak evidence that leans toward benefit.[AHRQ 2016]

For non-radicular chronic low back pain, there is moderate evidence to support physical therapy[AHRQ 2016], particularly utilizing the McKenzie method. [23],[24] Acupuncture also has moderate-strength evidence to support its benefit in this population. Tai chi, Yoga, psychological techniques (such as biofeedback and progressive relaxation), Spinal manipulation, and multidisciplinary rehab all have weak evidence that leans toward benefit.[AHRQ 2016],[25] Back schools also have very weak evidence of benefit.[26] As far as pharmacologic management of chronic low back pain, NSAIDs and duloxetine demonstrate ongoing benefit, while opioids only demonstrate short-term benefits.[AHRQ 2016] Gabapentin is a very commonly used anticonvulsant for chronic pain; however, it has not demonstrated a significant benefit for patients with chronic low back pain.[27]Topiramate, however, has been found to be more effective than placebo.[28] Topical anesthetics such as lidocaine patches and transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo.[29],[30]

According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year.[31] However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, Spinal fusion, or lumbar disk replacement.[31],[32],[33]

In Children:

In pediatrics, treatments for pain are less well studied. However, activity modification, physical therapy, and NSAIDs have broad support as first-line therapies.[8] If there is an underlying malicious cause present, treatment of those underlying disorders is the standard of care. A majority of spondylolysis may be managed conservatively as above, but some will need a referral for surgical intervention. Persistent symptoms after greater than 6 months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation.[34],[35],[36],[37] In patients with Scheuermann’s kyphosis, physical therapy and guided exercise may be sufficient for patients with less than 60 degrees curvature, bracing may be added for patients with curvature less than 70 degrees. Surgical correction may be indicated for the patient with greater than 75 degrees curvature, especially if they have failed conservative measures and are skeletally mature.[38],[39] Scoliosis of 20 degrees or more during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for surgical referral.[40]

Differential Diagnosis

The differential diagnosis for back pain is very broad, especially when considering the pediatric population. Below is a review of the more common diagnoses along with history or physical exam features that may increase your index of suspicion. This list is not comprehensive but represents the more likely and more concerning conditions that make up the differential.

Adults[41][1][42][43]

  • Lumbosacral muscle strains/sprains
    • Presentation: follows traumatic incident or repetitive overuse, pain worse with movement, better with rest, restricted range of motion, tenderness to palpation of muscles
  • Lumbar spondylosis
    • Presentation: patient typically is greater than 40years old, pain may be present or radiate from hips, pain with extension or rotation, the neurologic exam is usually normal
  • Disk herniation
    • Presentation: usually involves the L4 to S1 segments, may include paresthesia, sensory change, loss of strength or reflexes depending on severity and nerve root involved
  • Spondylolysis, Spondylolisthesis
    • Presentation: similar to pediatrics, spondylolisthesis may present back pain with radiation to the buttock and posterior thighs, neuro deficits are usually in the L5 distribution
  • Vertebral compression fracture
    • Presentation: localized back pain worse with flexion, point tenderness on palpation, may be acute or occur insidiously over time, age, chronic steroid use, and osteoporosis are risk factors
  • Spinal stenosis
    • Presentation: back pain which can be accompanied with sensory loss or weakness in legs relieved with rest (neurologic claudication), neuro exam normal.
  • Tumor
    • Presentation: a history of metastatic cancer, unexplained weight loss, focal tenderness to palpation in the setting of risk factors
    • Clinical note: 97% of spinal tumors are metastatic disease; however, the provider should keep multiple myeloma in the differential
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
    • Presentation: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery, fever, wound in the spinal region, localized pain, and tenderness
    • Clinical note: Granulomatous disease may represent as high as one-third of cases in developing countries.
  • Fracture
    • Presentation: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes

Pediatrics[44][45][46][47][48][49]:

  • Tumor
    • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis
    • Clinical note: Osteoid osteoma is the most common tumor that presents with back pain - classically, the pain is promptly relieved with anti-inflammatory drugs such as NSAIDS
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
    • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis
    • Clinical notes: Epidural abscess should be a consideration with the presence of fever, spinal pain, and neurologic deficits or radicular pain; discitis may present with a patient refusing to walk or crawl
  • A herniated disk, slipped apophysis
    • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal forward flexion, recent onset scoliosis
  • Spondylolysis, spondylolisthesis, lesion or injury to the posterior arch
    • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal extension, tight hamstrings
  • Vertebral fracture
    • Presentation: acute pain, other injuries, traumatic mechanism of injury, neurologic loss
  • Muscle strain
    • Presentation: acute pain, muscle tenderness without radiation
  • Scheuermann’s kyphosis
    • Presentation: chronic pain, rigid kyphosis
  • Inflammatory spondyloarthropathies
    • Presentation: chronic pain, morning stiffness lasting greater than 30min, sacroiliac joint tenderness
  • Psychological Disorder (conversion, somatization disorder)
    • Presentation: normal evaluation but persistent subjective pain
  • Idiopathic Scoliosis:
    • Presentation: positive Adam’s test (for larger angle curvature), most commonly asymptomatic
    • Clinical note: Of note, no definitive evidence that scoliosis causes pain, but patients with scoliosis have more frequently reported pain; therefore the provider should rule out other causes before attributing pain to scoliosis

Prognosis

Many factors seem to predict worse outcomes for patients who suffer from back pain. Prior episodes of back pain, greater intensity of back pain, and the presence of leg or widespread symptoms are all associated with worse “chronic disabling pain.” Lifestyle activities also seem to play a role including patients having higher body mass indexes (greater than 25) and smoking contributing to worse outcomes. Depression, catastrophizing, and fear avoidance behavior all worsen outcomes, including disability rates. There are also underlying social factors that have significant prognostic accuracy. These factors all have significant interplay such as low educational attainment, having a job that requires significant physical workloads, poor compensation, and poor job satisfaction all negatively impact outcomes.[50][51][52][53][54]

There is less clear prognostic evidence for pediatrics. However, one valid assumption is that the prognosis largely relies on the underlying etiology of the pain. The pain caused by cancer will likely have a different impact on disability than a muscle strain. Similarities exist in the pediatric population and adults, however. In regards to non-specific back pain, some studies lean toward increasing back pain with behavioral comorbidities such as conduct problems, ADHD, and psychological distress, passive coping strategies, and fear-avoidance behavior.[55][56][57][58][59]

Complications

Complications are largely determined based on underlying etiology; however, they can mostly subdivide into physical and social complications. Physically, complications can include cauda equina syndrome, chronic pain, and deformity (in select conditions). Socially, complications are usually measured by disability, decreased gross domestic product, and increased absenteeism. A study in 2015 found that back pain was responsible for 60.1million years lived with disability worldwide. This data represents the most common cause of disability globally.[60] In the US low back pain accounts for the most common reason for disability.[61]

Deterrence and Patient Education

After review of the evidence, it would seem that the best patient education that can be provided to prevent back pain is to maintain healthy body weight with a BMI less than 25, as higher BMI correlates with worse outcomes.[50] Patients of all ages should avoid smoking, as increases rates of back pain in all ages.[62][63] Continuing to engage in physical activity as fear-avoidant behaviors worsen disability. There is strong evidence that intensive patient education lasting for 2.5 hrs discussing activity modification, staying active, and early return to normal activity is more effective for returning to work.[64] There is mixed evidence about whether book bag weight plays a role in pediatric back pain,[65][22] but despite the unclear evidence the American Academy of Pediatrics recommends that book bags do not exceed 10 to 20% of the child’s body weight.[AAP 2004]

Pearls and Other Issues

There are practice pearls worth remembering in the evaluation and treatment of back pain.

For Adults[66][67][68][69][70][71][72][73][74]:

  • History and physical exam are sufficient for evaluation of non-traumatic, acute back pain in the absence of red flags - avoid imaging before six weeks in acute back pain in the absence of red flags
  • NSAIDs, opioids, and topiramate are more effective than placebo in the short-term treatment of nonspecific chronic low back pain
  • Acetaminophen, antidepressants (except duloxetine), lidocaine patches, and TENS are not consistently more effective than placebo in the treatment of chronic low back pain
  • Consider a physical therapy referral for McKenzie method techniques to reduce the risk of recurrence; intensive patient education that includes advice to stay active, avoid aggravating movements, and return to normal activity as soon as possible is effective in patients with nonspecific pain

For Children[75][59][76]:

  • Children with back pain who have no significant physical findings, a short duration of pain, and a history of minor injury can be treated conservatively with no further evaluation
  • Children with back pain either abnormal physical findings, constant pain, nighttime pain, or radicular pain should receive further evaluation
  • Anterioposterior and lateral plain films are the first line radiographic studies
  • Consider laboratory evaluation to accompany your radiographs as malignancy and infection are higher on the differential diagnosis for pediatric patients over adults
  • Tumor and infection needs to be ruled out for back pain in children 4 years and younger

Enhancing Healthcare Team Outcomes

Back pain affects millions of people and is a leading cause of chronic pain and disability. It also leads to higher costs of healthcare.

Back pain, if not treated appropriately, can become chronic and debilitating over time. There is some debate as to the most appropriate treatment for back pain to maximize outcomes. The confusion lies within the way studies have been framed in the past, by isolating the pain away from the other factors that make up the patient. Disease-oriented medicine, with treating back pain as a primarily isolated issue has proven to have relatively poor outcomes in regards to chronic back pain.  Approaching the treatment of pain from an interprofessional approach maximizes the chances of having better outcomes. 

The physical therapist should be involved early in the care and urge the patient to exercise regularly. The dietitian should encourage a healthy diet and body weight maintenance. The nurse practitioner should educate the patient on the harms of a sedentary lifestyle and should encourage abstinence from alcohol and tobacco.

Nursing should assist the clinical team with educating the patient on non-narcotic pain medications and possibly on alternative means of pain control including yoga, deep breathing, and acupuncture. Clinicians should refrain from empirically prescribing narcotics as they lead to addiction, tolerance, and abuse. In the rare instances when narcotics are prescribed, both the pharmacist and clinician should work together to avoid long-term prescriptions of controlled drugs.

Bearing in mind the clinical clues which provide worse prognostic outcomes such as underlying mental health disorders, kinesiophobia, obesity, and smoking, it is likely to be helpful to treat the whole patient with an interprofessional team. Screening for some of these comorbidities as a primary care provider may be of assistance if the patient is not responding to conservative therapy. The primary physician can also offer smoking cessation and other lifestyle management counseling to the patient. The interprofessional team should communicate with each other to prevent duplication of treatments and tests, and this also helps deliver the same message to the patient.

Outcomes

The addition of early physical therapy has shown benefit more rapid improvement of health care utilization and opioid use.[77] [Level I] The addition of a provider skilled in cognitive behavioral therapy may assist with patients with an underlying mood disorder that can contribute to symptoms as well as the development of coping skills.[78] [Level I] Interventions aimed at lowering the patient's weight may also provide significant back pain relief; however, the evidence is not as compelling.[79] [Level IV] 


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