Low Back Pain

(source: ICSI)

LBP: does not radiate past the knee
Sciatica: LBP radiating past the knee

Triage

• Recent procedure or epidural anesthesia
• Location: LBP or sciatica
• Duration: acute is less than 6 weeks, chronic is more than 6 weeks
• Injury: How?
• Pain scale
• Medical conditions
• Prior back pain or surgery
• Psychosocial indications

History

• Fracture
• Infection
  - IVDU, Immunosuppresion, UTI, Fever
• Tumor/Malignancy
  - >50yo, Hx of Cancer, UWL (Unexplained Wt Loss), No improvement after 4-5 weeks of conventional treatment
  - if none are present, studies = 100% sensitivity Cancer is ruled out
• AAA (added from Australian Guidelines)
  - sudden, with hypotension, collapse; abdominal pain radiating to back
• CES
  - urinary retention (in no urinary retention, likelihood of CES is less than 1:10,000)
  - saddle anesthesia, unilateral or bilateral sciatica, sensory or motor deficit, abnormal SLR
• S/S Neurologic Findings
  - leg numbness/weakness
  - sciatica with radiation past the knee (increases likelihood of radiculopathy)
  - sciatica: 95% sensitivity; its absence makes lumbar disc herniation unlikely
  - >95% of lumbar disc herniations area in L4-5, L5-S1; therefore focus on L5 S1 nerve roots
• Psychosocial
  • Belief that pain and activity are harmful
  • "Sickness behaviors," such as extended rest
  • Depressed or negative moods, social withdrawal
  • Treatment that does not fit best practice
  • Problems with claim and compensation
  • History of back pain, time off or other claims
  • Problems at work or low job satisfaction
  • Heavy work, unsociable hours
  • Overprotective family or lack of support

PE

• palpate for spinal tenderness
• Neuromuscular test:
  - Ankle dorsiflexion strength
  - Great toe dorsiflexion strength
  - Ankle reflexes
  - Knee reflexes
  - Knee extension
  - Hip flexors
  - Sensory exam with pinprick sensation in the medial, dorsal and lateral aspects of the foot
  - Significant or progressive neuromotor deficit requires surgical consultation.
• SLR
  - Positive SLR, defined as pain in the posterior leg that radiates below the knee with lying supine and the hip flexed 60 degrees or less, is suggestive of disc herniation.
  - Negative SLR rules out surgically significant disc herniation in 95% of cases.

LABS

• suspicion for Cancer or infection

Referral

• early referral to PT is recommended
• severe incapacitating, disabling back or leg pain
• significant limitation of functional or job activities

Indications of LXR (AP, Lateral) Link
* Oblique view x-rays are not recommended; they add only minimal information in a small percentage of cases, and more than double the exposure to radiation.