AssessmentandManagementofAcuteLowBackPain

ROBERTL.BRATTON,M.D.,MayoClinicJacksonville,Jacksonville,Florida
AmFamPhysician.1999Nov1560(8):22992306.
Seerelatedpatientinformationhandoutonlowbackpain(http://www.aafp.org/afp/1999/1115/p2307.html),writtenbytheauthorofthisarticle.
Acutelowbackpainiscommonlytreatedbyfamilyphysicians.Inmostcases,onlyconservativetherapyisneeded.However,thehistoryandphysical
examinationmayelicitwarningsignalsthatindicatetheneedforfurtherworkupandtreatment.Theseredflagsincludeahistoryoftrauma,fever,
incontinence,unexplainedweightloss,acancerhistory,longtermsteroiduse,parenteraldrugabuse,andintenselocalizedpainandaninabilitytogetinto
acomfortableposition.Treatmentusuallyconsistsofnonsteroidalantiinflammatoryagentsoracetaminophenandagradualreturntousualactivities.
Surgeryisreservedforuseinpatientswithsevereneurologicdeficitsand,possibly,thosewithseveresymptomsthatpersistdespiteadequate
conservativetreatment.
Lowbackpainisaproblemthatfamilyphysiciansconfrontintheirpatientsalmostdaily.ItissoprevalentthattheAgencyforHealthCarePolicyandResearch
(AHCPR)oftheU.S.DepartmentofHealthandHumanServiceshasdevelopedandpublishednationalguidelinestoassistprimarycarephysiciansintheappropriate
careofaffectedpatients.1A23membermultidisciplinarycommitteecompiledtheguidelines,whichfocusonlowbackpainoflessthanthreemonths'duration.This
reviewincorporatesmanyofthatcommittee'srecommendations.

Epidemiology
Lowbackpainisoneofthetop10reasonspatientsseekcarefromafamilyphysician.2Inepidemiologicstudiesofdifferentpopulations,theprevalenceoflowback
painhasvariedfrom7.6to37percent.Peakprevalenceisinthegroupbetween45and60yearsofage,3althoughbackpainisalsoreportedbyadolescentsandby
adultsofallages.
Consideringtheoverallexpensesinvolvedintreatinglowbackpain,theconditionhasbroadimplications.Eightypercentofadultsseekcareatsometimeforacutelow
backpain,andonethirdofalldisabilitycostsintheUnitedStatesareduetolowbackdisorders.4Thedirectcostsofdiagnosingandtreatinglowbackpaininthe
UnitedStateswereestimatedin1991tobe$25billionannually.Indirectcosts,includinglostearnings,areevenhigher.5Effectivediagnosisandtreatmentoflowback
paincansavehealthcareresourcesandrelievesufferinginamultitudeofpatients.

DurationofSymptoms
Backpainisclassifiedintothreecategoriesbasedonthedurationofsymptoms.Acutebackpainisarbitrarilydefinedaspainthathasbeenpresentforsixweeksor
less.Subacutebackpainhasasixto12weekdurationandchronicbackpainlastslongerthan12weeks.6
Usingthesethreecategories,wecanmakepredictionsaboutprognosis.Atleast60percentofpatientswithacutelowbackpainreturntoworkwithinonemonth,and
90percentreturnwithinthreemonths.7Withminimalintervention,mostpatientsimproveinthefirstfewweeks.

ClinicalCategoriesofLowBackPain
Lowbackpaincanbecausedbymanyconditions,bothseriousandbenign.Becauseofthis,theAHCPRhasgroupedbackpainintothreecategories:potentially
seriousspinalconditions,sciaticaandnonspecificbacksymptoms.

POTENTIALLYSERIOUSSPINALCONDITIONS
Spinaltumor,infection,fractureandthecaudaequinasyndromearepotentiallyseriouscausesofacutelowbackpain.Theseconditionsaresuggestedby
characteristicfindingsfromthehistoryandphysicalexamination(Table1).Immediatefurtherworkupandtreatmentareusuallyneeded.
View/PrintTable

TABLE1
CausesofLowBackPain

CONDITION

CLINICALCLUES

Nonspecificbackpain(mechanicalbackpain,facetjointpain,
osteoarthritis,musclesprains,spasms)

Nonerverootcompromise,localizedpainoverlumbosacralarea

Sciatica(herniateddisc)

Backrelatedlowerextremitysymptomsandspasminradicularpattern,positivestraightlegraisingtest

Spinefracture(compressionfracture)

Historyoftrauma,osteoporosis,localizedpainoverspine

Spondylolysis

Affectsyoungathletes(gymnastics,football,weightlifting)painwithspineextensionoblique
radiographsshowdefectofparsinterarticularis

Malignantdisease(multiplemyeloma),metastaticdisease

Unexplainedweightloss,fever,abnormalserumproteinelectrophoresispattern,historyofmalignant
disease

Connectivetissuedisease(systemiclupuserythematosus)

Fever,increasederythrocytesedimentationrate,positiveforantinuclearantibodies,scleroderma,
rheumatoidarthritis

Infection(discspace,spinaltuberculosis)

Fever,parenteraldrugabuse,historyoftuberculosisorpositivetuberculintest

Abdominalaorticaneurysm

Inabilitytofindpositionofcomfort,backpainnotrelievedbyrest,pulsatilemassinabdomen

SCIATICA
Backrelatedlowerextremitysymptomssuggestnerverootcompromise.Sciaticaisoftendebilitatingbut,inmostcases,thepainabateswithconservativetherapy.

NONSPECIFICBACKSYMPTOMS
Somepatientshavesymptomsprimarilyinthebackthatsuggestneithernerverootcompromisenoraseriousunderlyingcondition.1Mechanicallowbackpainisinthis
category.Thesepatientsalsousuallyimprovewithconservativetreatment.
Withthisclinicalclassification,theexaminercanusethehistoryandphysicalfindingstospecifythetypeofbackpainaffectingthepatientandproperlytreatpatients
whohavepotentiallyseriousspinalconditions.

History
Thediagnosisoflowbackpainrequiresacarefulhistorytodeterminewhetherthecausesaremechanical,orsecondaryandmorethreatening.Mechanicalcausesof
acutelowbackpainincludedysfunctionofthemusculoskeletalandligamentousstructures.Paincanoriginatefromthedisc,annulus,facetjointsandmusclefibers.
Mechanicallowbackpaingenerallyhasafavorableoutcome,butbackpainwithasecondarycauserequirestreatmentfortheunderlyingcondition.
Fortunately,secondarycausesoflowbackpainaremuchlessfrequentthanmechanicalcauses.Animportantconsiderationinthepatient'shistoryisage.Patients
olderthan50andyoungerthan20aremorelikelytohavesecondarycauses.ClinicalfindingsthatmayindicateanunderlyingdiseasearelistedinTable1.
Lesscommonsecondarycausesofacutelowbackpainincludemetabolicdiseases,inflammatoryrheumatologicdisorders,referredpainfromothersources,Paget's
disease,fibromyalgiaandpsychogenicpain8,9(Table2).
View/PrintTable

TABLE2
DifferentialDiagnosisofLowBackPain
Primarymechanicalderangements
Ligamentousstrain
Musclestrainorspasm
Facetjointdisruptionordegeneration
Intervertebraldiscdegenerationorherniation
Vertebralcompressionfracture
Vertebralendplatemicrofractures
Spondylolisthesis
Spinalstenosis

Diffuseidiopathicskeletalhyperostosis
Scheuermann'sdisease(vertebralepiphysealasepticnecrosis)
Infection

Ingeneral,cluestosecondarycausesoflowbackpaincanbefoundinthehistoryandphysicalexamination.Thesearereferredtoasredflags,andtheywarrant
furtherdiagnosticworkupandimmediatetreatment(Table3).
View/PrintTable

TABLE3
RedFlagsforAcuteLowBackPain
History
Cancer
Unexplainedweightloss
Immunosuppression
Prolongeduseofsteroids
Intravenousdruguse
Urinarytractinfection
Painthatisincreasedorunrelievedbyrest
Fever
Significanttraumarelatedtoage(e.g.,fallfromaheightormotorvehicleaccidentinayoungpatient,minorfallorheavyliftinginapotentiallyosteoporoticorolderpatientoraperson
withpossibleosteoporosis)
Bladderorbowelincontinence

PhysicalExamination
Thephysicalexaminationisnotasimportantasthehistoryinidentifyingsecondarycausesofacutelowbackpain.Nevertheless,certainaspectsofthephysical
examinationareconsideredimportant.

GAITANDPOSTURE
Observationofthepatient'swalkandoverallpostureissuggestedforallpatientswithlowbackpain.Scoliosismaybefunctionalandmayindicateunderlyingmuscle
spasmorneurogenicinvolvement.

RANGEOFMOTION
Theexaminershouldrecordthepatient'sforwardflexion,extension,lateralflexionandlateralrotationoftheuppertorso.Painwithforwardflexionisthemostcommon
responseandusuallyreflectsmechanicalcauses.Ifpainisinducedbybackextension,spinalstenosisshouldbeconsidered.Unfortunately,theevaluationofspinal
rangeofmotionhaslimiteddiagnosticuse,10althoughitmaybehelpfulinplanningandmonitoringtreatment.

PALPATIONORPERCUSSIONOFTHESPINE
Pointtendernessoverthespinewithpalpationorpercussionmayindicatefractureoraninfectioninvolvingthespine.Palpatingtheparaspinousregionmayhelp
delineatetenderareasormusclespasm.

HEELTOEWALKANDSQUATANDRISE
Apatientunabletowalkheeltotoe,andsquatandrisemayhaveseverecaudaequinasyndromeorneurologiccompromise.

PALPATIONOFTHESCIATICNOTCH
Tendernessoverthesciaticnotchwithradiationtothelegoftenindicatesirritationofthesciaticnerveornerveroots.

STRAIGHTLEGRAISINGTEST
Withthepatientinthesupineposition,eachlegisraisedseparatelyuntilpainoccurs.Theanglebetweenthebedandthelegshouldberecorded.Painoccurringwhen
theangleisbetween30and60degreesisaprovocativesignofnerverootirritation(Figure1,top).Bendingthekneewhilemaintaininghipflexionshouldrelievethe
pain,andpressureinthepoplitealregionshouldworsenit(poplitealcompressiontest).11Ifplacingthekneebackinfullextensionduringstraightlegraisingand

dorsiflexingtheanklealsoincreasethepain(Lasgue'ssign),nerverootandsciaticnerveirritationislikely.
Therightsholderdidnotgrantrightstoreproducethisiteminelectronicmedia.Forthemissingitem,seetheoriginalprintversionofthispublication.
FIGURE1.

Theresultofstraightlegraisingispositivein95percentofpatientswithaprovenherniateddiscatsurgery,butitisalsopositivein80to90percentofpatientswithout
anyformofdiscprotrusionatsurgery.12Incontrast,crossedstraightlegraisingislesssensitivebutmuchmorespecificfordischerniation.Inthecrossedstraightleg
raisingtest,thecontralateral,uninvolvedlegisraised(Figure1,bottom).Thetestresultispositivewhenpainisproduced.

REFLEXESANDMOTORANDSENSORYTESTING
Testingkneeandanklereflexesinpatientswithradicularsymptomsoftenhelpsdeterminethelevelofspinalcordcompromise.Analteredkneeoranklereflexalone
doesnotsuggesttheneedforinvasivemanagementbecausethisfindingisgenerallytransientandfullyreversible.8
WeaknesswithdorsiflexionofthegreattoesandanklemayindicateL5andsomeL4rootdysfunction.Sensorytestingofthemedial(L4),dorsal(L5)andlateral(S1)
aspectsofthefootmayalsodetectnerverootdysfunction.1

LIMITEDNEUROLOGICTESTING
Intheprimarycareofpatientswithlowbackpainandlegsymptoms,theneurologicexaminationcanbelimitedtojustafewtests.Theseincludethetestingof
dorsiflexionstrengthoftheankleandgreattoe,anklereflexesandlighttouchoveraspectsofthefoot,aswellasthestraightlegraisingtest.Thisabbreviated
neurologicexaminationofthelowerextremitiesallowsthedetectionofmostclinicallyimportantradiculopathyrelatedtolumbardischerniation.Ifpatientswith
abnormalfindingsonthesetestsdonotshowimprovementbyonemonth,furtherdiagnosticworkuporreferraltoaspecialistisnecessary.8Thosewithprogressive
symptomsshouldundergofurtherevaluationwithoutdelay.

LaboratoryTests
Laboratorytestsgenerallyarenotnecessaryintheinitialevaluationofacutelowbackpain.Iftumororinfectionissuspected,acompletebloodcellcountand
erythrocytesedimentationrateshouldbeobtained.1Otherbloodstudies,suchastestingforHLAB27antigen(presentinankylosingspondylitis)andserumprotein
electrophoresis(resultsabnormalinmultiplemyeloma),arenotrecommendedunlessclinicallywarranted.Additionallaboratorytests,suchasurinalysis,shouldbe
tailoredtothepossiblediagnosessuggestedbythehistoryandphysicalfindings.

RadiographicEvaluation
Plainradiographsarenotrecommendedfortheroutineevaluationofacutelowbackpainwithinthefirstmonthunlessafindingfromthehistoryandclinical
examinationraisesconcern(Table4).13Ifredflagssuggestcaudaequinasyndromeorprogressivemajormotorweakness,thepromptuseofcomputedtomography
(CT),magneticresonanceimaging,myelographyorcombinedCTandmyelographyisrecommended.Intheabsenceofredflagsafteronemonthofsymptoms,itis
reasonabletoobtainanimagingstudyifsurgeryisbeingconsidered.1
View/PrintTable

TABLE4
SelectiveIndicationsforRadiographyinAcuteLowBackPain
Age>50years
Significanttrauma
Neuromotordeficits
Unexplainedweightloss(10lbinsixmonths)
Suspicionofankylosingspondylitis
Drugoralcoholabuse
Historyofcancer
Useofcorticosteroids
Temperature37.8C(100.0F)
Recentvisit(within1month)forsameproblemandnoimprovement
Patientseekingcompensationforbackpain

Treatment
Mostpatientsrequireonlysymptomatictreatmentforacutelowbackpain.Infact,about60percentofpatientswithlowbackpainreportimprovementinsevendays
withconservativetherapy,andmostnoteimprovementwithinfourweeks.14Patientsshouldbeinstructedtowatchforworseningsymptomssuchasanincreasingloss
ofmotororsensoryfunctions,increasingpainandthelossofbladderorbowelfunction.Shouldanyoftheseoccur,thepatientshouldundergofurtherevaluationand
treatmentimmediately,withweeklyfollowup.
Patientsshouldgraduallyreturntotheirnormalactivities,astolerated.Continuingordinaryactivitieswithinthelimitspermittedbypainleadstoamorerapidrecovery
thaneitherbedrestorbackmobilizingexercises.15
Patientswithacutelowbackproblemsbenefitfromexerciseprograms,ifstartedearlyandiftheexercisescauseminimalmechanicalstressontheback.Thegoalof
anexerciseprogramis,first,topreventdebilitationrelatedtoinactivityand,second,toimproveactivitytoleranceandreturnpatientstotheirhighestleveloffunctioning
assoonaspossible.1
Medicationscommonlyusedforthetreatmentofacutelowbackpainincludeaspirinandothernonsteroidalantiinflammatorydrugs(NSAIDs),acetaminophenand,
possibly,musclerelaxants.Patientstakingopioidanalgesicdrugs,oftenusedinthefirstfewdaysafterthedevelopmentofacutelowbackpain,donotreturntofull
activitysoonerthanpatientstakingNSAIDsoracetaminophen.16MusclerelaxantsaremoreeffectivethanplacebobutnobetterthanNSAIDsinrelievingacutelow
backpain.Oralcorticosteroidsandantidepressantsdonotappeartobeeffectiveinpatientswithacutelowbackpain,andtheiruseisnotrecommended.1
Spinalmanipulationhasbeenshowninseveralrandomizedtrialstobebeneficial.17Shoeinsolesoverthecounterfoamorrubberinsertsandcustommadeorthotics
mayalsobebeneficialinsomepatients.Spinaltraction,transcutaneouselectricalnervestimulation,biofeedback,triggerpointinjections,facetjointinjectionsand
acupunctureareusuallynothelpfulinthemanaagementofacutelowbackpain.1Surgerymaybeindicatedinselectedpatientswhoarenothelpedbyconservative
treatmentandwhohavedebilitatingsymptomsafteronemonthoftherapy.Patientswithredflagsnotedattheinitialevaluationmaybecandidatesforimmediate
surgery.

DifficultiesinDiagnosingAcuteLowBackPain
Nonorganicfactorsaresometimesimportantcontributorstothesymptomsofacutelowbackpain.Psychosocialfactorscanbeeconomic(e.g.,greaterfinancial
compensationwhennotworking)orsocial(e.g.,jobdissatisfaction).Anotherfactorispendinglitigation.Todeterminewhetherpsychosocialfactorsarerelevant,the
examinercanobtainpaindrawingsbyaskingthepatienttomarkthetypeanddistributionofthepainonafigureofthehumanbody.Ifthedistributionisnonanatomic,
apsychogeniccauseishighlylikely.18TheWaddelltests,asetoffivemaneuverseasilyperformedduringaroutinephysicalexamination,identifypatientsinwhom
nonorganicissuesplayanimportantroleinthepersistenceofsymptoms(Table5).19
View/PrintTable

TABLE5
Waddell'sTestsforNonorganicPhysicalSigns
TEST

INAPPROPRIATERESPONSE*

Tenderness

Superficial,nonanatomictendernesstolighttouch

Simulation
Axialloading

Verticalloadingonastandingpatient'sskullproduceslowbackpain

Rotation

Passiverotationofshouldersandpelvisinsameplanecauseslowbackpain

Distraction

Discrepancybetweenfindingsonsittingandsupinestraightlegraisingtests

Regionaldisturbances

Overreaction

Weakness

Cogwheel(giveway)weakness

Sensory

Nondermatomalsensoryloss
Disproportionatefacialexpression,verbalizationortremorduringexamination

*Threeormoreinappropriateresponsessuggestcomplicatingpsychosocialissuesinpatientswithlowbackpain.

TheAuthor
ROBERTL.BRATTON,M.D.,isaconsultantintheDepartmentofFamilyMedicineattheMayoClinicJacksonville,inJacksonville,Fla.,andassistantprofessorof
familymedicineattheMayoMedicalSchool,Rochester,Minn.HegraduatedfromtheUniversityofKentuckyCollegeofMedicine,Lexington,andcompleteda
residencyinfamilymedicineattheMayoClinicinRochester,Minn.Dr.BrattonwasamajorcontributortotheAmericanBoardofFamilyPracticereferenceguideon
lowbackpain,publishedin1997.

AddresscorrespondencetoRobertL.Bratton,M.D.,MayoClinicJacksonville,4500SanPabloRd.,Jacksonville,FL32224.Reprintsarenotavailablefromtheauthor.

CopiesoftheClinicalPracticeGuidelineno.14,AcuteLowBackProblemsinAdults:AssessmentandTreatment,areavailable(cost:$5)fromtheAgencyforHealth
CarePolicyandResearchPublicationsClearinghouse,P.O.Box8547,SilverSpring,MD20907telephone:18003582925Website:http://www.ahcpr.gov
(http://www.ahcpr.gov).

REFERENCES showallreferences
1.BigosSJ,BowyerOR,BraenGR,BrownK,DeyoR,HaldemanS,etal.Acutelowbackproblemsinadults.Clinicalpracticeguidelineno.14(AHCPRpublicationno.

950642).Rockville,Md.:U.S.DepartmentofHealthandHumanServices,PublicHealthService,AgencyforHealthCarePolicyandResearch,December1994....

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