para>Back pain is not normal in children and must be carefully evaluated. Patients participating in gymnastics or other high impact sports (such as skateboarding and cheerleading) frequently land on their feet or buttocks. These can result in a vertebral fracture and/or damage to the intervertebral discs. á
PHYSICAL EXAM
- Observe gait, position on examination table, and facial expressions.
- Test lumbar spine range of motion.
- Evaluate for point tenderness or muscle spasm.
- Neurologic examination. Inspection: signs of muscle atrophy
- Completely evaluate reflexes, strength, pulses, sensation
- Straight leg test
- FABER test (flexion, abduction, and external rotation)
- Stork test: Stand on one leg with opposite hip held in flextion. Extend back. Pain in lumbosacral area is a positive test.
DIFFERENTIAL DIAGNOSIS
- Localized/nonspecific "mechanical"Ł LBP (87%) (1)[A]
- Lumbar strain/sprain (70%)
- Disc/facet degeneration (10%)
- Osteoporotic compression fracture (4%)
- Spondylolisthesis (2%)
- Severe scoliosis, kyphosis
- Asymmetric transitional vertebrae (<1%)
- Traumatic fracture (<1%)
- Back pain with lower extremity symptoms (7%) (1)[A]
- Disc herniation (4%)
- Spinal stenosis (3%)
- Systemic and visceral symptoms (1)[A]
- Neoplasia (0.7%)
- Multiple myeloma; metastatic carcinoma
- Lymphoma/leukemia
- Spinal cord tumors, retroperitoneal tumors
- Infection (0.01%)
- Osteomyelitis
- Septic discitis
- Paraspinous abscess; epidural abscess
- Shingles
- Inflammatory disease (0.03%)
- Ankylosing spondylitis, psoriatic spondylitis
- Reactive arthritis
- Inflammatory bowel disease
- Visceral disease (0.05%)
- Prostatitis
- Endometriosis
- Chronic pelvic inflammatory disease
- Nephrolithiasis, pyelonephritis
- Perinephric abscess
- Aortic aneurysm
- Pancreatitis; cholecystitis
- Penetrating ulcer
- Other
- Osteochondrosis
- Paget disease
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Imaging studies are unnecessary during the first 6 weeks if no red flag signs or symptoms.
- X-ray of the lumbar spine (1,3,4)[A]
- Not recommended for initial presentation or without red flags including trauma. Defer films for 6 weeks unless there is a high risk of disease.
- Useful for bony etiology (e.g., fracture)
- MRI of the lumbar spine (1,3,4)[A] for patients presenting with neurologic deficits, failure to improve with 6 weeks of conservative treatment, or if there is a strong suspicion of cancer or cauda equina syndrome.
- Useful for suspected herniated disc, nerve root compression, or metastatic disease
- CT scan of the lumbar spine (1,3,4)[A]
- Appropriate alternative to MRI for patient with pacemaker, metallic hardware, or other contraindication to MRI
- Labs are unnecessary with initial presentation if no related red flags, signs, or symptoms present (1,3,4)[A]
- If infection or bone marrow neoplasm is suspected, consider (1,3,4)[A]
- Complete blood count (CBC) with differential
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP) level
Diagnostic Procedures/Other
- Neurosurgical consult for acute neurologic deficits or suspected cauda equina syndrome (1,4)[A]
TREATMENT
The primary goal is to provide supportive care and allow return to functional activity. Patients should be aware of alarm symptoms that prompt a return visit. á
First Line
- Patient education (4)[A]
- Reassure patients that pain is usually self-limited; treatment should relieve pain and improve function.
- Encouraging activity as tolerated leads to quicker recovery.
- Medications (1,3,5)[A]
- Acetaminophen 325 to 650 mg PO q4h-q6h PRN pain (max 4 g/day)
- NSAIDs
- Ibuprofen 400 to 600 mg PO 3 to 4 times daily (max 3,200 mg/day)
- Naproxen 250 to 500 mg PO q12h (max 1,500 mg/day)
- Manual medicine (4)[A], osteopathic manipulative treatments (OMT) (4)[A],(6)[B]: myofascial, counter-strain, bilateral ligamentous techniques, as well as muscle energy, if tolerated
- Obstetric considerations (6,7)[B]
- Use medications cautiously in pregnancy-benefit must clearly outweigh risk.
- OMT and chiropractic care may be used in a multidisciplinary approach may be used in the general population as well as the obstetric patient.
Second Line
- Second-line therapy for moderate to severe pain (1,3,5)[A]
- Cyclobenzaprine 5 to 10 mg PO up to TID PRN (max 30 mg/day)
- Tizanidine 2 mg PO up to TID PRN
- Hydrocodone 2.5 to 10 mg PO q4h-q6h PRN pain; use of hydrocodone or other opioids for LBP is based on clinical judgment.
- Other treatments (1,3)[A]
- Antidepressants (1,3,5)[A]
- Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) have been shown in randomized trials to provide a small pain reduction in patients. No clear evidence that SSRIs are more effective than placebo in cases of chronic LBP.
- Injections (8)[A]
- Facet: lumbar radiofrequency neurotomy, therapeutic facet joint nerve blocks in the lumbar spine and lumbar intra-articular injections have all shown benefit
- Epidural: Provide short-term relief of persistent pain associated with documented radicular symptoms caused by herniated disc (1,3,4,8)[A]
Geriatric Considerations
Older persons taking nonselective NSAIDs should use a proton pump inhibitor or misoprostol for gastrointestinal protection.
Patients taking a COX-2 selective inhibitor with aspirin should use a proton pump inhibitor or misoprostol for gastrointestinal protection.
Age-related decline in cytochrome P-450 function and polypharmacy (common in elderly patients) increases risk for adverse medication reactions.
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COMPLEMENTARY & ALTERNATIVE MEDICINE
- Acupuncture is superior to no treatment, but evidence is mixed regarding the effectiveness of acupuncture over other treatment modalities (1,3,4)[A].
- Yoga can help with chronic LBP (1,3,4)[A].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Regular exercise (3,9)[A]
- Patient education regarding chronicity, recurrence, and red flags (3,9)[A]
Patient Monitoring
- Reassurance is key. Follow up within 2 to 4 weeks of initial presentation to monitor progress. Most patients spontaneously improve.
- Assess severity and quality of pain as well as range of motion and other historical features (red flags).
- Reevaluate for possible underlying organic causes for pain if patients fail to improve.
COMPLICATIONS
- Regular NSAID use can increase risk of gastrointestinal toxicity and nephrotoxicity (1,4)[A].
- Acetaminophen has potential hepatotoxicity (1,4)[A].
- Centrally acting skeletal muscle relaxants and opioid agonists carry the risk for sedation, confusion, dependence, and abuse (1,4)[A].
REFERENCES
11 Golob áAL, Wipf áJE. Low back pain. Med Clin North Am. 2014;98(3):405-428.22 Duffy áRL. Low back pain: an approach to diagnosis and management. Prim Care. 2010;37(4):729-741.33 Chaparro áLE, Furlan áAD, Deshpande áA, et al. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine (Phila Pa 1976). 2014;39(7):556-563.44 Casazza áBA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.55 Lee áTJ. Pharmacologic treatment for low back pain: one component of pain care. Phys Med Rehabil Clin N Am. 2010;21(4):793-800.66 Hensel áKL, Buchanan áS, Brown áSK, et al. Pregnancy research on osteopathic manipulation optimizing treatment effects: the PROMOTE study. Am J Obstet Gynecol. 2015;212(1):108.e1-108.e9.77 George áJW, Skaggs áCD, Thompson áPA, et al. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. 2013;208(4):295.e1-295.e7.88 Manchikanti áL, Kaye áAD, Boswell áMV, et al. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician. 2015;18(4):E535-E582.99 Savigny áP, Watson áP, Underwood M; Guideline Development áGroup. Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ. 2009;338:b1805.
ADDITIONAL READING
- de Leon-Casasola áOA. Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am J Med. 2013;126(3) (Suppl 1):S3-S11.
- Engers áA, Jellema áP, Wensing áM, et al. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057.
- Flynn áTW, Smith áB, Chou áR. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-846.
- Henschke áN, Ostelo áRW, van Tulder áMW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;(7):CD002014.
- Hutchinson áAJ, Ball áS, Andrews áJC, et al. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012;7:36.
- Kuijpers áT, van Middelkoop áM, Rubinstein áSM, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20(1):40-50.
- Urquhart áDM, Hoving áJL, Assendelft áWW, et al. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev. 2010;(1):CD001703.
- Walker áBF, French áSD, Grant áW, et al. A Cochrane review of combined chiropractic interventions for low-back pain. Spine (Phila Pa 1976). 2011;36(3):230-242.
SEE ALSO
- Lumbar (Intervertebral) Disc Disorders
- Algorithm: Low Back Pain, Acute
CODES
ICD10
- M54.5 Low back pain
- G89.29 Other chronic pain
- M53.3 Sacrococcygeal disorders, not elsewhere classified
- M54.40 Lumbago with sciatica, unspecified side
- M54.41 Lumbago with sciatica, right side
- M54.42 Lumbago with sciatica, left side
ICD9
- 724.2 Lumbago
- 338.19 Other acute pain
- 724.6 Disorders of sacrum
- 338.29 Other chronic pain
SNOMED
- 279039007 low back pain (finding)
- 278862001 acute low back pain (finding)
- 134407002 chronic back pain (finding)
- 202487003 Sacroiliac joint pain (finding)
CLINICAL PEARLS
- LBP is one of the most common complaints in primary care. Most patients do not have an identifiable cause of pain, and most cases resolve spontaneously within 4 to 12 weeks of onset.
- Assess for red flag symptoms in every patient.
- Labs and imaging studies are unnecessary for most cases of back pain if no red flag symptoms are present.
- In the absence of red flags, physical activity as tolerated speeds recovery.