Acute lower back pain
Medhat Michail
September 2017
Case 1
• A 35 years old male presented with severe pain in his lower
back after bending down to pick up a heavy weight.
• No radiation of the pain to the lower limbs
• PH: Nil
• O/E:
– stands with increased lordosis and reduced forward flexion,
walking is painful
– tender over L5 and paravertebral muscles
– No neurological S/S
• What is the diagnosis?
• How would you manage this patient?
Case 2
• A 37 years old male presented with severe pain in his lower back
after bending down to pick up a heavy weight.
• The pain is radiating down the back of his left leg as far as the ankle
• PH: Nil
• O/E:
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Walks with pain
↓ back movements especially the forward flexion
The muscle power was difficult to assess because of the pain
Normal ankle dorsiflexion (bilaterally) but weak left ankle planter flexion
and big toe flexion
– Altered sensation over the lateral side of the left foot
– No other neurological S/S
• What is the diagnosis?
• How would you manage this patient?
Dermatomes of the lower limb,
Front & back
Movements generated by myotomes of the lower
limb
(Drake R, Vogl W, Mitchell A. Gray's anatomy for
students. Churchill Livingstone, Edinburgh; 2004)
Movement
Innervation
Hip flexion
L1 L2
Knee extension
L3 L4
Knee flexion
L5 S1 S2
Hindfoot inversion
L4
Great toe dorsiflexion
L5
Ankle plantarflexion
S1 S2
Back pain
• Is the leading cause of occupational
disability in the world
• The most common cause of missing work
days
• 50 - 80%
• With aging population and sedentary live
this situation is unlikely to change
Aim
To provide an evidence based overview of
low back pain to the primary health carer
Objectives
By the end of this presentation you should
be confident in managing patients with back
pain in the ED.
Common causes of low back pain
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Mechanical (80 – 90%)
Neurogenic (5 – 15%)
Non-mechanical spinal conditions (1 – 2%)
Referred visceral pain (1 – 2%)
Other (2 -4 %)
Mechanical causes (80 – 90%)
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Unknown causes
Degenerative disc or joint disease
Vertebral fracture
Congenital deformity
Spondylolysis
instability
Neurogenic causes (5 – 15%)
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Herniated disc
Spinal stenosis
Osteophytic nerve root composition
Annular fissue with chemical irritation to
the nerve root
• Failed back surgery syndrome
• Infections (e.g. herpes zoster)
Non-mechanical spinal conditions
(1 – 2%)
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Neoplastic (primary or secondary)
Infection (osteomyelitis, discitis or abscess)
Inflammatory arthritis
Paget’s disease
Other (e.g. Sheuermann’s disease, Baastrup’s
disease)
Referral visceral pain (1 – 2 %)
• GI diseases
• Renal diseases
• AAA
Other (2 - 4%)
• Fibromyalgia
• Somatoform disorder
• Mallingering
Classification by Edlow 2015
• Simple causes
– Muscular & ligamentous strains
– Isolated sciatica (Posterolateral disc herniation)
– Spinal stenosis
• Serious causes
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Cancer related
Infection related
Spinal epidural haematoma
Central disc herniation causing cauda equina syndrome
• Non-spine related causes
Management of acute low back pain in ED
• Rule out the serious causes
• Pain management
Red flags
• Cauda equina Syndrome
• Spine fractures
• Malignancy or infection
Red flag symptoms indication possible
serious spinal pathology.
Red flag symptoms are:
•Onset at age <20 or >55
•Non-mechanical pain (i.e. unrelated to
time or activity), especially if constant and
worsening, and pain at night
•Thoracic pain
•Previous history of carcinoma, steroids or
HIV infection
•Fever, night sweats, weight loss
•Widespread neurological symptoms
especially sphincter disturbance
•Structural spinal deformity
Red Flags – Cauda equina syndrome
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Saddle anesthesia or paresthesia
Recent onset of bladder dysfunction
Recent onset of faecal incontinence
Perianal/perineal sensory loss
Unexplained laxity of the anal sphincter
Severe or progressive neurological deficits in the
lower limbs
Red Flags – spinal fracture
– Sudden onset of severe central pain in the spine
which is relieved by lying down.
– Major trauma such as a road accident or fall from a
height.
– Minor trauma, or even just strenuous lifting, in people
with osteoporosis.
– Structural deformity of the spine (such as a step from
one vertebra to an adjacent vertebra).
– Point tenderness over the vertebral body
Red flags – Malignancy or infection
• Pain that remains when lying down, aching night-time pain that
disturbs sleep, and thoracic pain could also be caused by an aortic
aneurysm.
• Onset in people aged above 50 years or below 20 years.
• History of cancer.
• Constitutional symptoms, such as fever, chills, or unexplained
weight loss.
• Recent bacterial infection - eg, urinary tract infection.
• Intravenous drug misuse.
• Immune suppression.
• Structural deformity of the spine (such as scoliosis).
• Point tenderness over the vertebral body.
Investigations
• No investigations are required in majority
of cases
• Limited role of X ray in non traumatic low
back pain
• Lab investigations if red flags are present
The Biomarkers
• Routine lab testing is not useful
• WBCs
– elevated only in 2/3 of patients with epidural abscess
• CRP & ESR
– Highly sensitive but non specific
– ESR & CRP not recommended for patients with no red flags
Pharmacological treatment
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Simple analgesia
NSAID
Opiates
Steroids
Muscle relaxant
So the evidences……?
• First line agents (Paracetamol & NSAID)
– Paracetamol is ineffective
Machado 2015
Australian Institute of health & welfare, 2010
– NSAID
No difference over placebo when added to
paracetamol
Machado 2017
So the evidences……?
• Steroids
No benefit
• In herniated disc (Goldberg 2015)
• In undifferentiated patients (Eskin 2014)
• Muscle relaxants & Opiates
No benefit (Swaminathan 2017)
• Cyclobenzaparine & Naproxen
No benefit (Friedman 2015)
• Opiates & Paracetamol
No benefit in pain control or functional outcome at 1/52 & 3/12
(Friedman 2015)
The real Management
• Discussing expectations
– Likely to have pain for 6/52 (Menezes Costa 2012)
– Up to 60% will have pain and decrease
function after one year
• Educate your patient
• Medications
• Discharge instructions: verbal & leaflet
Key recommendations (NICE
Nov. 2016)
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Paracetamol
Oral NSAIDs
Weak opioids
Imaging
Physical & Psychological Programme
Regular activities
Group Exercise
Massage & manipulation
Acupuncture, electrotherapies & spinal injections
Epidural injections
Radiofrequency Denervation