Low-back Pain

  1. In a patient with undefined acute low-back pain (LBP):

    1. Rule out serious causes (e.g., cauda equina syndrome, pyelonephritis, ruptured abdominal aortic aneurysm, cancer) through appropriate history and physical examination.

    2. Make a positive diagnosis of musculoskeletal pain (not a diagnosis of exclusion) through an appropriate history and physical examination.

  2. In a patient with confirmed mechanical low back pain:

    1. Do not over-investigate in the acute phase.

    2. Advise the patient:

      • that symptoms can evolve, and ensure adequate follow-up care.

      • that the prognosis is positive (i.e., the overwhelming majority of cases will get better).

  3. In a patient with mechanical low back pain, whether it is acute or chronic, give appropriate analgesia and titrate it to the patient’s pain.

  4. Advise the patient with mechanical low back pain to return if new or progressive neurologic symptoms develop.

  5. In all patients with mechanical low back pain, discuss exercises and posture strategies to prevent recurrences.

DDx Low-Back Pain

  • Serious (RED FLAGS)

    • Cord Compression (Urinary/Fecal incontinence/retention, saddle anesthesia, motor weakness/numbness)

    • Infectious - Discitis/epidural abscess/pyelonephritis (Fever, IV drug use, severe, recent surgery, recent infection, immunocomprised)

    • Metastatic Cancer (Hx, weight loss, age>50, persist, night pain, pain at rest)

    • Vertebral Fracture (Osteoporosis, steroid use, age, trauma)

    • Ruptured AAA (pulsations)

    • Spondyloarthritis (Improvement with exercise, pain at night (with improvement upon getting up/activity), insidious onset, age <40 years, no improvement at rest, inflamamtory arthritis, enthesitis, uveitis, psoriasis, family history)

  • Radicular pain (leg pain, sensory loss, reduced reflex, myotomal weakness)

    • Intervertebral disc herniation

  • Neurogenic claudication (Bilateral buttock/thigh/leg pain, pseudoclaudication)

    • Central spinal canal stenosis

  • Non-specific (mechanical)

  • Beyond lumbar spine

    • Gyne

    • Renal (kidney stones)

    • GI

    • Hip joint

Physical Exam

  • Vitals (Temperature)

  • Gait/Posture

    • Heel-toe, Squat and Rise

  • Spine

    • Abnormalities

    • ROM

      • Schober's test (marks at 5cm below L5 and 10cm above, flexion should increase distance from 15 to >20cm)

    • Vertebral Tenderness

  • Waddell's Signs (Non-organic)

    • Superficial or nonanatomic tenderness

    • Simulation test

      • Axial loading

      • Rotation of shoulder/Pelvis in same plane

    • Distraction

      • Discrepency between sitting and supine straight leg raise

    • Regional disturbances

      • Cogwheel (give-way) weakness

      • Nondermatomal sensory loss

    • Overreaction

  • Straight Leg Raise

  • Motor/Sensory (Saddle anesthesia, sphincter tone)

    • DF ankle, EHL

  • Reflexes

  • Joint above and below (eg. hip)

    • FABER for SI joint

Investigations rarely needed initially unless red flags

  • CBC, ESR (tumor, infection)

  • SPEP (multiple myeloma)

  • X-ray (fractures)

  • X-ray or CT Sacroiliac joints (ankylosing spondylitis)

    • HLA-B27 antigen (ankylosing spondylitis)

  • MRI (cauda equina)


Acute or subacute low back pain

  • Nonpharmacologic treatment

    • Superficial heat (moderate-quality evidence)

    • Massage, acupuncture, or spinal manipulation (low-quality evidence)

    • Maintain activity and re-assurance (95% improve in 6 weeks)

  • Pharmacologic treatment

    • Topical NSAIDs

    • NSAIDs (eg. ibuprofen 600mg PO QID) or skeletal muscle relaxants (eg. cyclobenzaprine 10mg PO TID) (moderate-quality evidence)

Chronic low back pain

  • Nonpharmacologic treatment

    • Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence)

    • Tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence)

  • Pharmacologic treatment

    • NSAIDs as first-line therapy

    • Tramadol (50-100mg PO QID) or Duloxetine (30-60mg PO daily) as second-line therapy

    • Opioids if failed above (weak recommendation, moderate-quality evidence)

      • Keep opioids <90mg morphine equivalents if possible