This is a 3-part Blog that looks at some of the more common concerns providers have when treating patients who present with back pain. In Part 1 we will look at acute non-traumatic musculoskeletal origins of back pain. We talk about key historical, physical exam, diagnostic imaging and treatment options that are associated with MSK back pain. In Part 2 we focus on neurologic origins the back pain. We address historical, physical exam, diagnostic imaging and treatment options used to treat neurologic origin back pain. We will provide recommendations for follow up care based on physical exam findings that involve only sensory and motor changes and those urgent presentations that demand your immediate attention. Finally, in Part 3 we address those emergent non-spine origins for back pain. Providers should be aware that abdominal aortic aneurysms (AAA), acute cholangitis, and retroperitoneal hematomas can present as back pain.
Part 1 Acute non-traumatic musculoskeletal origins of back pain
Back pain is one of the most common musculoskeletal (MSK) complaints that patients present with to the Emergency Department, Urgent Care, and Primary Care settings. The majority of adults will present with non-traumatic acute/chronic MSK back pain. The role of the non-MSK providers is to determine between acute emergent neurologic onset back pain vs. the non-emergent MSK origin of back pain. This assessment will be based on the patients’ historical information, physical examination findings, diagnostic studies and using sound evidence-based clinical judgment. In order to expand providers knowledge in the evaluation and treatment of patients presenting with back pain, we will divide the Back Pain into 3 categories; 1) acute, non-traumatic MSK origins, 2) Back pain with neurologic manifestations and 3) Non-spine related origins.
Acute, non-traumatic MSK origins
The majority of patients who present with musculoskeletal back pain have a muscle injury or related cause for their pain symptoms. Patients describe a lifting, twisting, or a sudden movement that precipitates the onset of symptoms.1-3 Things like lifting a heavy bag of groceries out of the car, lifting a child in/out of a car seat or a sudden sneeze or a cough can all contribute to the onset of MSK back pain.1-4 Patients will not describe long-standing pain, will not have any radicular symptoms and will usually have a fairly benign medical history. Patients will deny fevers, chills, incontinence, or histories of worsening back pain. These patents will lack any history of malignancy, previous spine surgery, spine trauma or recent spinal injections.2 However, it is not uncommon for patients who have had repeated bouts of MSK back pain to have a history of degenerative disc disease (without neurologic symptoms) or spondylolysis/listhesis. These conditions can exacerbate the onset of muscular symptoms.2-4
The most common physical examination finding associated with MSK back pain is largely pain with movement (bending, twisting, lifting, getting in/out of a car/chair/toilet, in/out bed). Their symptoms are usually better with lying supine and non-strenuous activities can actually make their symptoms less intense.2,5 They may have muscular tenderness in the lumbar region on palpation. As mentioned, mobility is limited and they will have trouble and will have trouble with trunk flexion/extension and lateral bending.6,7 Strength in the lower extremities (Hip-Knee-Ankle-Toe) is usually intact. However, pain with resistive muscle testing may be diminished 2nd to pain with these maneuvers.8 If there is a question about weakness (2nd to pain vs neurologic impairment) a follow-up exam in a few days is necessary. Reflexes (Patella-Achilles) are intact bilaterally. Remember, some patients will have difficulty relaxing in order to get a reliable reflex assessment.8 Pulses should be documented but do not have a direct correlation with MSK back pain. In MSK back pain, performing a straight-leg-raise test can produce transverse low back pain but does not illicit radiculopathy. Patients with MSK back pain can have tight hamstrings, so simply extending their leg can pull on the tight hamstring and cause pain.1-5,9 This pain should not be misinterpreted as radiculopathy. A patient who has a history of Spondylolisthesis or Spondylolysis is not predisposed to having associated neurologic deficits. The abnormalities in the vertebrae will contribute to changes in normal spine mechanics and can result in MSK injuries when excessive forces a transmitted across these areas.1,2
The medical literature states that in MSK back pain presentations, without neurologic deficit, radiographs are not warranted.5,8,9 [Author’s note: I routinely obtain imaging in patients who present with MSK back pain. I order Standing Lumbar AP, Lateral and Oblique views. This allows me to assess for vertebral body fractures, disc space changes and to assess the pars interarticularis for Spondylopathy]. In most cases, x-ray images are interrupted as negative for patients presenting with MSK back pain.8,9 When x-ray imaging is obtained and findings of “new” onset Spondylosis/Spondylolisthesis are found, this should not be interpreted as an acute fracture (unless there is a history of trauma). If there is a concern about the acuity of new-onset Spondylopathy, based on x-ray images, then either CT scan or MRI imaging should be obtained prior to discharge.1,2,8,9 [Authors note: I prefer to use MRI imaging in these cases. MRI will reveal bone edema, at the pars interarticularis, which directly correlates to acute injury.]
There are many options available in the treatment of MSK back pain. In reviewing the literature, protected moderate activity seems to provide a better reduction in back pain symptoms vs prolonged bed rest (>2 days). Patients will frequently ask if heat or ice is more effective in treating MSK back pain. In my clinical experience, I believe both heat and ice play a role in symptom relief.5,6,9 I will instruct patients to alternate Ice (20 minutes) and heat (heating pad 20 minutes) 4-5 times a day for 1 week. The “freeze and thaw” helps to minimize muscle swelling and tightness. I try to encourage patients to avoid lying on a heating pad while sleeping. Aside from the fact they could suffer a thermal burn, the constant heat can worsen muscle stiffness.5,6,9 I like to incorporate a referral to physical therapy (PT), in my treatment protocol, to help patients address core body strength, flexibility and postural conditions that can greatly contribute to MSK back pain.7 While patients may not be happy about the expense or the disruption to their normal daily routine, the ones who do participate in PT do better in the long-term (symptom relief and preventing reinjury). 7,9 Regarding medication therapy, non-steroidal analgesics (NSAID) and acetaminophen have proved to be effective in treating MSK pain.11 Some patients may present with more severe pain symptoms than usual. In those patients, I may use a 6-day taper corticosteroid dose pack. I avoid steroid dose packs in patients who have diabetes and those who are taking autoimmune suppressive medications.6 Once the patient has completed the dose pack, then, I may have them start on an NSAID as needed. I try to limit NSAID use to 7-10 days. I avoid NSAID use in those with known aspirin allergy, the elderly (>65), those with known kidney disease, those on anticoagulation medication and patients with a history of GI bleed.11 Once the patient has completed the dose pack then I will instruct them to start taking NSAIDs as needed. In some situations, the use of muscle relaxant medications may be helpful in reducing muscle spasms. However, great caution should be exercised when prescribing muscle relaxant medications as it can increase the patient’s fall risk.1-3 The question frequently comes up regarding when to use narcotic analgesics to treat MSK back pain. I try to avoid prescribing these medications since NSAIDs and acetaminophen have proven to do an adequate job of relieving pain.1,2,11 However, just like with muscle relaxants, narcotics can contribute to an increase in fall risk. Therefore, I try to limit prescribing narcotics but if I do prescribe them it is for no more than 7 days. If the patient requires more medication, then they need to be seen for reassessment.
The key to treating MSK back pain is listening to what patients tell you, being confident in your physical examination skills, knowing what the diagnostic imaging tells you and developing an effective treatment plan. If you ever are uncertain about the acuity of injury, repeating the exam in a few days is appropriate. If you are suspicious of an evolving emergent condition, immediate referral or consultation is appropriate and, in some cases, getting advanced radiographic imaging, prior to referral is warranted.
- Singleton J, Edlow JA, Acute Nontraumatic Back Pain: Risk Stratification, Emergency Department management, and Review of serious Pathologies, Emerg Med Clin N Am 2016;34:743-757.
- Maher C, Underwood M, Buchbinder R, Non-specific low back pain Lancet 2017;389:736-47.
- Golob AL, Wipf JE, Low Back Pain, Med Clin North Am, 2014;98(3):405-428 doi: 10.1016/j.mcna.2014.01.003.
- Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, et al. (2018) Patients’ perceived needs for medical services for non- specific low back pain: A systematic scoping review. PLoS ONE 13(11): e0204885.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of lowback pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478–91.
- National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. London: National Institute for Health and Clinical Excellence, 2009. https://www.nice.org.uk/guidance/cg88/evidence/fullguideline-243685549 (accessed December 19, 2018).
- Van Middelkoop M, Rubinstein SM Verhagen AP et al, Exercise therapy for chronic nonspecific low-back pain, Best Practice & Research clinical Rheumatology, 2010 24:193-204.
- Hoppenfeld, SA, Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels, Lippincott, Philadelphia, 1997:45-74, 93-101.
- Friedman BW, Chilistrom M, Bjur PE, et al, Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective, Spine 2010;35:1406-1411.
- Anderson JC, Is immediate imaging important in managing low back pain? J Ath Train 2011;46(1):99-120.
- Friedman BW, Dym AA, Davitt M et al, naproxen with cyclobenzaprine, oxycodone/acetaminophen; or placebo for treating acute low back pain: a randomized clinical trial, JAMA 2015;314(15):1572-80.