Back Pain
Diagnosis/Definition
A condition of pain in the lower (lumbar-sacral) back region, with or without radiation of symptoms to the buttocks or lower extremities, in the non-pregnant patient.
Initial Diagnosis and management
- Elicitation of history and performance of physical examination. Special attention to presence or absence of “red flags” to include: age <18 or >55; history of malignancy, steroid use, or HIV positivity; weight loss or constitutional symptoms; structural deformity; anal or urethral sphincter disturbance; saddle anesthesia; gait disturbance; or widespread neurologic deficit.
- If red flags are present, diagnostic testing may include plain radiographs; CBC; ESR; bone scan; CT scan and/or MRI scan and electrodiagnosis as indicated.
- If red flags are absent a diagnostic workup is generally not necessary.
Initial treatment
The first 2 weeks:
- reassurance that most episodes resolve uneventfully within 6 weeks;
- encouragement to maintain as close to normal activity as is tolerable;
- avoidance of bed rest greater than 24 hours;
- NSAIDS (nonsteroidal anti-inflammatory drugs, unless contraindicated);
- muscle relaxants for up to one week;
- acetaminophen as needed;
- weak opiates (codeine; propoxyphene) unless contraindicated;
- passive modalities (e.g. ice, heat) for symptomatic relief,
- Work/duty limitations.
Ongoing management and objectives
- If pain has not improved in 2 weeks: re-evaluate for “red flags”, change NSAID, and consider referral to Physical Therapy for evaluation and treatment while continuing to follow patient.
- Self care Information: Warm up before any sports activity; Participate in a conditioning program to build muscle strength; Do stretching exercises daily
Indications for referral to specialty care
Focal neurologic signs with abnormal imaging studies (urgent consult if worsening) – Neurosurgery or Orthopedics referral with xrays done.
Consider MRI prior to referral (without contrast unless tumor suspected).
Focal neurologic signs with normal imaging studies (urgent if worsening) Neurology referral.
Incapacitating radiculopathy unresponsive to therapy – Neurosurgery or Orthopedic referral. MRI of lumbar spine prior to referral (without contrast usually).
Abnormal plain radiographs associated with red flags – Neurosurgery or Orthopedics referral. MRI of lumbar spine prior to referral (without contrast usually).
Loss of bladder or bowel control – (urgent) Neurosurgery referral.
Extra-spinal conditions such as, Urologic, GI, Gynecologic, Vascular, Neurologic, Rheumatologic, or Systemic – referral to subspecialty appropriate to affected organ system.
If pain has not improved within 6 weeks, refer to Physical Medicine and Rehabilitation for evaluation and management.
Referral criteria for return to Primary Care
Resolution of symptoms; or, implementation of continuing treatment program that can be managed in primary care portal with periodic subspecialty follow-up.
Persistence of back pain without true radicular symptoms > 6 months – consider permanent profiling addressing such as lifting limitations and sit-up limitations.
