Evaluation and Management of Radicular Low Back Pain - Stacie Kasper DO
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Evaluation and Management
of Radicular Low Back Pain
Stacie Kasper DO
Disclosures: None
Low Back Pain
Common condition encountered in primary care.
First episode usually occurs between 20 and 40 years of age
Annual incidence of 15% and lifetime prevalence of 60-90%.
Leading cause of disability in United States for adults younger than age 45.
Also accounts for 1/3 of workers compensation costs.
Only 2% of patients with acute LBP have a herniated disk.
Most patients who experience activity limiting low back pain go on to have recurrent
episodes.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Herring, W. (2012). Learning Radiology Recognizing the Basics (2nd ed.). Elsevier.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
History of Present Illness
PQRST
Precipitating/palliating factors
Quality
Radiation
Severity
Temporal factors
OLD CARTS
Onset
Location
Duration
Character
Aggravating/associated factors
Relieving factors
Temporal factors
Severity
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Types of Musculoskeletal Complaints
Joint complaints
Muscular complaints
Skeletal complaints
Injury
Back pain
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Prevention
LBP is heavy medical and financial burden
USPSTF insufficient evidence to support or rebuke routine use of exercise as a preventative
measure for acute low back pain.
However, regular physical activity has been show to be beneficial in the treatment and
limitation of recurrent episodes of chronic low back pain.
Lumbar supports (back belts) not effective
Worksite interventions- i.e., lifting technique, has shown to have some short-term effects on
decreasing loss of time from work for patients with low back pain
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierBack Pain History
Location and distribution: unilateral or bilateral, radiation to buttocks, groin, or legs
Abrupt or gradual onset
Duration of pain: acute under 6 weeks, chronic over 6 weeks
First or recurrent episode
Character of pain and sensation
Mechanical, radicular, claudicate or nonspecific
Tearing, burning, steady ache, tingling or numbness.
Triggered by coughing or sneezing and sudden movements
Associated event: trauma, occupational and nonoccupational lifting, of heavy weights, long distance driving, sports
activities, change in posture or deformity
Neurological symptoms: bowel or bladder symptoms, weakness in extremities, saddle anesthesia
Associated symptoms: fever, weight loss, night pain
Efforts to treat: rest, avoiding standing or sudden movements, chiropractic
Medications: muscle relaxants, analgesics, alterative or complementary therapies.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.htmlPast Medical History
Trauma
Surgery on bone or joint
Chronic illness
Cancer
Arthritis
Sickle cell anemia
Hemophilia
Osteoporosis
Renal disorder
Neurological disorder
Skeletal deformities or congenital anomalies
Immunosuppression: history of cancer, steroid use, HIV infection
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierFamily History
Congenital abnormalities of hip/foot
Scoliosis or back problems
Arthritis: rheumatoid, osteoarthritis, ankylosing spondylitis, gout
Genetic disorders
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierPersonal and Social History
Employment: past and current, lifting and potential for unintentional injury, safety precautions,
use of spinal support
Exercise- extent, type and frequency, weight-bearing, stress on certain joints.
Functional abilities: personal care (eating, bathing, dressing, grooming, elimination) other
activities (housework, walking, stairs, caring for pet)
Weight
Height
Nutrition
Tobacco use
Alcohol use
Drug use
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierRED FLAGS
Major trauma
Age >50
Persistent fever
History of cancer
Metabolic disorder
Major muscle weakness
Bladder or bowel dysfunction- i.e. Decreased sphincter tone
Saddle anesthesia
Unrelenting night pain
Prolonged corticosteroid use
Spinal procedure in past 12 months
IV drug use
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.htmlLumbosacral Radiculopathy (Herniated
Lumbar Disk)
Herniation of lumbar disk that irritates the corresponding nerve root and results in muscle
weakness, paresthesia and pain in the distribution of the nerve root dermatome.
Generally caused by degenerative changes of the disk.
Most commonly occurs at L4, L5 and S1 nerve roots
Greatest incidence occurs between ages 31 and 50 years.
Commonly associated with lifting heavy objects while the arms are extended and spine is
flexed
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier Common symptoms include low back pain with radiation to the buttocks and posterior
thigh or down the leg in the distribution of the dermatome of the nerve root.
Numbness, tingling, or weakness may occur in the involved extremity.
Spasm and tenderness over the paraspinal musculature may also be present.
Patient may have difficulty with heel walking (L4 and L5) or toe walking (S1).
Pain in lower extremity is often described as burning, may be unilateral or bilateral or
alternating sides
Sneezing and coughing or bending toward the affected side often induce or aggravate
the pain. Pain relief often achieved by laying down
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierLumbar Stenosis
Usually caused by hypertrophy of ligamentum flavum and facet joints that results in
narrowing of spinal canal.
Narrowing may lead to entrapment of the nerve roots.
Signs and symptoms include pain with walking or standing that often seems to originate in
the buttocks and may then radiate down the legs, followed by pain relief with sitting.
Pain in lower extremities may be worsened by prolonged standing, walking, bending or
hyperextending the back.
Pain is generally relieved by sitting down.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierExamination
Inspection:
Observation- gait and posture. Note how the patient walks, sits, rises from sitting position
Inspect skin- discoloration, swelling and masses
Observe extremities- size, gross deformity, alignment, symmetry
Inspect muscles- gross hypertrophy or atrophy fasciculations, spasms.
Palpation
Bones, joints and surrounding muscles- note heat, tenderness, swelling, fluctuation, crepitus, pain resistance to pressure
Range of Motion
Active and passive
Muscle Strength
0 no evidence of movement
1 trace movement
2 full range of motion, but not against gravity
3 full range of motion against gravity but not against resistance
4 range of motion against gravity and some resistance but weak
5 full range of motion against gravity, full resistance
Reflexes
Special Tests
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierDermatomes Reflexes
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain.
AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Dermatome. (2021). [Illustration]. https://www.ncbi.nlm.nih.gov/books/NBK535401/figure/article-
29335.image.f1/Straight Leg Raise Test
Test nerve root irritation or lumbar disk herniation at L4, L5, and S1
Patient lays supine with neck slightly flex, examiner raise the leg 30 to 70 degrees, keeping the
knee extended. No pain should be felt below the knee with leg raising. Pain below the knee in a
dermatome pattern may be associated with disk herniation. Pain at less than 60 degree is
positive for lumbar disk herniation (sensitivity 0.8, specificity 0.4)
Lasegue sign is positive when the patient is unable to raise the leg more than 30 degrees
without pain.
Pain less than 30 degrees may indicate non-organicity or hip joint
Pain more than 70 degrees likely from tight hamstrings or gluteal muscles
Flexion of the knee often eliminates the pain with leg raising.
Repeat with unaffected leg. Ie Cross SLRT or Fajerztajn sign
Crossover pain in the affected leg with this maneuver is more supportive of the finding of tension on
nerve roots. (sensitivity 0.35, specificity 0.9)
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/. https://www.ncbi.nlm.nih.gov/books/NBK545299/https://www.youtube.com/watch?v=LdAD9GNv8FI Straight Leg Raise or Lasègue’s Test for Lumbar Radiculopathy. (2016). Https://Www.Youtube.Com/Watch?V=LdAD9GNv8FI. https://www.youtube.com/watch?v=LdAD9GNv8FI Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Interpreting Result of SLRT
Pain down buttock to lateral thigh and medial calf=L4
Pain down buttock to posterior thigh and lateral calf = L5
Pain down buttock to posterior thigh and calf and lateral foot = S1
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/. https://www.ncbi.nlm.nih.gov/books/NBK545299/Braggard Stretch Test
Also tests for lumbar disk herniation at L4, L5 and S1 levels.
Have the patient lay supine with the neck slightly flexed. Hold the patient’s lower leg and
raise it slightly and briskly dorsiflex the foot and internally rotate the leg. Ask the patient to
locate the most distal point of pain. Pain below the knee when the leg is raised less than
70 degrees and aggravated by dorsiflexion and internal rotation of the hip is associated
with a herniated disk at L5 or S1 level.
Reverse flip test: while raising the leg the foot is held in plantar-flexed position; this will
lessen the pain. If patient complains of increase in pain it can suggest malingering
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/. https://www.ncbi.nlm.nih.gov/books/NBK545299/Neri Sign
Also tests for lumbar disk herniation at L4, L5 and S1 levels.
Have the patient lay supine. Hold the patient’s lower leg and raise it. Pain with flexion of
the head or if the patient flexes the knee to avoid stretching the nerve.
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/.
https://www.ncbi.nlm.nih.gov/books/NBK545299/Slump Test
With patient sitting and leaning slightly forward, ask patient to extend the leg at the knee
while you apply resistance. Pain with extension or resistance and attempts to lean
backward to reduce tension on the nerve is a positive sign of sciatic nerve tenderness
Range of Sensitivity 44-87% Specificity 23-63%
+ test indication of herniated disc or nerve root entrapment
https://www.youtube.com/watch?v=HFGfP84uwEo
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
The SLUMP Test. (2016). Https://Www.Youtube.Com/Watch?V=HFGfP84uwEo. https://www.youtube.com/watch?v=HFGfP84uwEoFemoral Stretch Test/Reverse Straight Leg
Or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3 and
sometimes L4 level.
Have the patient lie prone and extend the hip. No pain is expected. The presence of pain
on extension is a positive sign of nerve root irritation
Reverse straight leg raise: extend hip and flex knee while prone- L3 nerve root
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/. https://www.ncbi.nlm.nih.gov/books/NBK545299/https://www.youtube.com/watch?v=4VxKyPRq6HA
Reversed Lasègue or Prone Knee Bending Test. (2016). Https://Www.Youtube.Com/Watch?V=4VxKyPRq6HA.
https://www.youtube.com/watch?v=4VxKyPRq6HA
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierOther Tests
Sitting SLR (Bechterew Test): patient is made to sit at the edge of a table with both hip and knee flexed then
made to extend the knee join tor elevate the extended knee which reproduces the radicular pain. They
may be able to extend each leg along, but extending both together causes radicular pain
Distracted SLRT: sitting SLRT performed without patients awareness. Examin foot or pulsation and slowly
extend knee. If experiencing true radiculopathy, the same pain will be reproduced. If not assume patient
may be malingering.
Buckling sign: patient may flex knee during SLRT to avoid stretching the nerve
Sicard sign: passive dorsiflexion of ipsilateral great toe a the the angle of the SLRT will produce more pain
Kraus-Weber Test: patient may be able to do a sit-up with the knees flexed but not extended
Minor sign: patient may raise from a seated position but supporting themselves on the unaffected side,
bending forward, and placing one hand on the affected side of the back.
Bonnet phenomenon: pain may be more severe or elicited sooner if the test is carried out iwht the thigh and
leg in a position of adduction and internal rotation
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/. https://www.ncbi.nlm.nih.gov/books/NBK545299/Risk stratification
Look for red flags of serious underlying disorder.
Major trauma
Age >50
Persistent fever
History of cancer
Metabolic disorder
Major muscle weakness- abnormal gait with lack of heel to toe ambulation, foot drop
Bladder or bowel dysfunction- acute urinary retention, incontinence
Saddle anesthesia
Decreased sphincter tone
Unrelenting night pain
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP. https://www.aafp.org/afp/2015/0515/p708.html
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierRED FLAG and appropriate actions
Condition Red Flag Action
Cancer History of cancer If malignant disease suspected imaging is indicated
Unexplained weight loss and CBC and ESR considered. If primary suspected
Age over 50 investigate i.e. PSA, mammogram, UPEP/SPEP/IPEP
Failure to improve with therapy
Pain over 4-6 weeks
Night/rest pain
Infection Fever If infection of spine suspected MRI, CBC, ESR and or
History of IV drug use UA indicated
Recent bacterial infection- UTI, skin, pneumonia
Immunocompromised states (steroid, organ
transplants, HIV, DM)
Rest pain
Cauda Equina Syndrome Urinary retention or incontinence Request immediate surgical consultation
Saddle anesthesia
Anal sphincter tone decrease/fecal incontinence
Bilateral lower extremity weakness/numbness or
progressive neurological deficit
Fracture Use of corticosteroids Appropriate imaging and surgical consultation
Age over 70 or history of osteoporosis
Recent significant trauma
Acute abdominal aneurysm Abdominal pulsating mass Appropriate imaging (US) and surgical consultation
Other atherosclerotic disease
Rest/night pain
Age over 60
Significant herniated nucleus pulposus Major muscle weakness Appropriate imaging and surgical consultation
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-
261). McGraw-Hill.Masqueraders of LBP
Vascular: expanding AAA
GI: endometriosis, tubal pregnancy, kidney stone, prostatitis, chronic pelvic inflammatory
disease, peripheric abscess, pyelonephritis
Endocrine/metabolic: osteoporosis, osteomalacia, hyperparathyroidism, Paget's disease,
acromegaly, Cushing disease
Hematologic: hemoglobinopathy, myelofibrosis, mastocytosis
Rheumatologic: AS, Reiter's syndrome, psoriatic arthritis, enteropathic arthritis, Behcet
syndrome, Familial Mediterranean fever, whipple disease
Psychogenic: affective disorder, conversion disorder, somatization disorder, malingering
Infection: osteomyelitis, epidural/paraspinal abscess, disk space infection,
Neoplastic
Others: sarcoidosis, subacute endocarditis, herpes zoster
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierLabs
Reserve for patients suspected of having a condition
Cancer or infection
CBC, ESR, PSA, SPEP
Renal or urinary tract disease
BUN, creatinine, UA
Osteopenia, osteolytic vertebral lesions or vertebral body collapse
Calcium, phosphorus, alkaline phosphatase
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierImaging Studies
Diagnostic imaging rarely indicated in acute setting of low back pain
After first 4-6 weeks of symptoms the majority of patients have regained function.
HOWEVER, if still limited by back diagnostic imaging should be considered to look for other
conditions.
Children
Patients older than 50
Trauma
Patients whom fails to improve despite appropriate conservative treatment
“Must be interpreted carefully because disc degeneration and protrusion have been noted in 20-
25% of asymptomatic individuals” (Webb)
“does not modify patient outcomes” (Herdon)
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP. https://www.aafp.org/afp/2015/0515/p708.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierImaging Studies
Plain films
Widely available, inexpensive, demonstrate boney anatomy well
Rarely useful in absence of red flags
Anteroposterior and lateral views allow assessment of lumbar alignment, intervertebral disc
space, bone density and limited evaluation of soft tissue.
Oblique views should only be used when spondylolysis is suspected- double radiation exposure
and only add minimal information
Sacroiliac vies used to evaluate ankylosing spondylitis and should only be used when this is
suspected.
Plain lumbar radiographs are helpful in detecting spinal fractures and evaluating tumor or
infection.
Recommended to rule out fracture with acute LBP and red flags.
May be helpful in patients with labs (CBC, ESR) to rule out tumor or infection
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Herring, W. (2012). Learning Radiology Recognizing the Basics (2nd ed.). Elsevier.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierImaging Studies with Neurological deficits
If history and physical suggest anatomic abnormality as cause with neurologic deficits one of the four commonly used
Plain myelography
CT
MRI
CT myelography
These are used in similar clinical situations and provide similar information.
Object is to define a medically or surgically remediable anatomic condition.
These should not be done routinely and should only be used for patients who present with certain clinical findings such
as radicular symptoms and clinically detectable nerve root compressive symptoms severe enough to consider surgical
intervention (major muscle weakness, progressive motor deficit, intractable pain and persistent radicular pain beyond
6 weeks)
Other indications include history of neurogenic claudication suggestive of spinal stenosis, exam findings suggesting
cauda equina syndrome, spinal fracture, infection or tumor.
“For a patient with a neurologic deficit and positive tension sign (SLR with pain radiating below the knee) and
correlative imaging study the clinical accuracy is 95%”
MRI is most accurate followed by CT myelography
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). ElsevierMRI
Superior soft tissue differentiation, able to visualize and detect abnormalities of soft tissues
such as bone marrow, spinal cord, and intervertebral disk
Benefits- can look at any plane, and lack of exposure to radiation
Downside- expensive, availability not as wide spread as CT, patients with pacemakers or
internal ferromagnetic materials can’t be scanned. Time to complete. Claustrophobia
Most herniated discs occur posteriolaterally in spine.
Post laminectomy syndrome is persistent pain in back or legs following spine surgery-
Gadolium-enhanced MRI can be helpful in detecting the cause.
Degenerative disk disease increases with age.
Herring, W. (2012). Learning Radiology Recognizing the Basics (2nd ed.). Elsevier.CT
Ability to reformate images in different planes
Used in trauma often
Detects boney lesions not visible on conventional radiographs
Evaluate soft tissue of patients unable to undergo MRI
Herring, W. (2012). Learning Radiology Recognizing the Basics (2nd ed.). Elsevier.Treatment
Patient education
Activity modification
Bed rest
Medications
Spinal manipulation
Physical agents and modalities
Exercise
Behavioral therapy
Reevaluation
Referral
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Patient Education
Educate in office about expectations for recovering and potential recurrence of symptoms
Recall likely to reoccur
Inform of safe and reasonable activity modifications and information on how to limit recurrence
of low back problems through proper lifting techniques, treatment of obesity, and tobacco
cessation.
If medications used inform patient of side effects.
Tell to follow up in 1-3 weeks if they fail to improve with conservative treatment or develop
bowel or bladder dysfunction or worsening neurologic function
Strong evidence that intensive 2.5 hr educational sessions are more effective for return to work
and long term pain, less intensive patient education no more effective than no intervention
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.htmlActivity Modification
Patients may be more comfortable if temporarily limit or avoid specific activities that are
known to increase mechanical stress on the spine.
Prolonged unsupported sitting and heavy lifting (especially while bending and twisting
should be avoided
Take into account patients age, general health and physical demands of the job
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Bed Rest
Gradual return to normal activities is more effective than prolonged bed rest.
Bed rest longer than 4 days may lead to debilitating muscle atrophy and increased
stiffness.
Most patients do not require bed rest- however if severe initial symptoms 2-4 days is an
option.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Medications:
NSAIDS are more effective for short term symptomatic relief in patients with acute LBP. One NSAID has
not been shown to be more effective than another in treatment of LBP. No difference, however,
between NSAIDS and placebo for radicular symptoms. No difference between NSAIDS and opioids or
muscle relaxants for chronic pain
Adverse effects- dyspepsia, upper GI bleed, increased CV events, acute prerenal azotemia
Acetaminophen: no evidence better than placebo for chronic low back pain
Muscle relaxants moderate benefit for acute nonspecific low back pain. Most pain reduction from
these in first 7-14 days.
Potential side effects- abuse-carisoprodol, transient lower blood pressure- tizanidine, increased serotonin
syndrome- cyclobenzaprine. Sedation is common
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP. https://www.aafp.org/afp/2015/0515/p708.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html Anticonvulsants: gabapentin significant adverse effects without demonstrated benefits in patients with chronic low back pain- however may be effective than naproxen in short term for failed back surgery syndrome. Topiramate more effective than placebo for improvement in pain severity or functioning Opioids- no more effective in relieving low back symptoms than other analgesics (aspirin, acetaminophen) and potential for complications such as dependency if used limited time course Topical anesethetics: topical lidocaine patches no more effective than placebo for chronic LBP
Oral corticosteroids show no benefit according to randomized control trial (this was
prednisone in ER)
Antidepressants: no clear evidence of superiority over placebo except duloxetine in
patients with comorbid depression or other forms of chronic pain
Injections: trigger point, ligamentous, facet joint, epidural- invasive, exposure to possible
complications
Epidural and facet may benefit patients who fail conservative treatment as a means to avoid
surgerySpinal Manipulation- PT, OMT
Spinal manipulation attempts to restore joint and soft tissue ROM.
Useful after early after symptom onset for patients who have acute LBP without radiculopathy.
If progressive for severe neurologic deficit manipulation should be postponed until appropriate
diagnostic assessment.
Patients who have symptoms longer than 4-6 weeks despite manipulation should be
reevaluated.
McKenzie method- PT (approach that uses structure examination to classify patients with LBP to
identify those that will benefit from PT), shown moderate evidence for acute low back pain but
moderate to no difference chronic low back pain
OMT- effective at reducing acute and chronic mechanical low back pain
Massage: low to very low evidence for short term improvements in acute, subacute and
chronic low back pain.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.htmlPhysical Agents and Modalities
No well designed controlled trials to support or discourage the use of physical agents or
modalities for acute LBP
Physical agents: moist heat and cold treatments
Self administered at home are often administered, 20 min 2-3 times per day, although
moist heat should NOT be used in the first 72 hours after injury.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill. TENS provides pulse of electricity to injured area through surface electrodes.
According to gate-control theory this stimulations activates inhibitory interneurons in the spinal
cord thereby interfering with propagation of pain signals. Few studies- not more effective than
placebo, failed to improve functional status
Not more effective than placebo in treatment of chronic pain
Shoe insoles (or inserts) aim to reduce back pain due to leg length discrepancies or
abnormal foot mechanics during gait. Limited evidence that they may provide short term
benefit, no evidence supporting long term use.
Role of leg length discrepancies in LBP has not been established, difference under 2 cm not likely
to cause symptoms
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.html
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP. https://www.aafp.org/afp/2015/0515/p708.html Lumbar support devise: corsets, support belts, braces, molded jackets and back rests for chairs
and car seats.
Corsets and support belts may be beneficial in preventing LBP and reducing time lost from work for
individuals whose jobs require frequent lifting, however, evidence is lacking.
RCT found that mattresses of medium firmness are beneficial in reducing pain symptoms and
disability in patients with chronic LBP.
Acupuncture and dry needling techniques have not been found to be beneficial , however
recent evidence that traditional Chinese acupuncture and therapeutic massage beneficial in
treatment of chronic LBP
Acupuncture, when added to conventional therapies, improves function and pain better than
conventional therapy alone.
Dry needling useful as adjunct to other therapies and not useful in treatment of acute LBP
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Exercise
Therapeutic exercises should be started early to control pain, avoid deconditioning, and
restore function.
Hip muscles i.e. iliopsoas, rectus femorus and tight hamstrings.
Strengthen back, legs, abdomen
Yoga- strong evidence of short term effectiveness and moderate quality of evidence of
long term effectiveness for chronic low back pain
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.htmlBehavioral Therapy
Psychological stress (depression) has emerged as the strongest single baseline predictor of
4 year outcomes, exceeding pain intensity.
Fear avoidance beliefs influence recovery
Show why exercise is so important- reduces fear avoidance behavior and facilitates
function despite ongoing pain.
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Reevaluation
If a patients pain worsens during the time of symptom control, reevaluation and
consultation or referral to specialty care is recommended.
Reassess after 1-3 weeks to assess progress. f/u phone call or office visit.
Advise patients to follow up sooner if condition worsens.
Any worsening of neurologic symptoms warrants a complete reevaluation.
Conservative treatment for 4-6 weeks from initial evaluation.
At f/u consider ergonomic evaluation
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Referral
If patients has LBP more than 6 weeks despite an adequate course of conservative
therapy, patient should be reexamined in office.
Comprehensive evaluation including psychosocial assessment and physical exam.
At follow up visit identify detriments in patients condition- new neurological symptoms
increase in pain, new radiation of pain
Patients with pain that radiates below the knee, especially with positive tension sign,
anatomy should be evaluated with imaging
If there are abnormal findings consultation with neurosurgeon or back surgeon. If imaging
is ok nonsurgical back management specialist .
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Specialist Indications
Physiatrist, PMR Chronic back pain more than 6 wk
Chronic sciatica more than 6 wk
Chronic pain syndrome
Recurrent back pain
Neurology Chronic sciatica for more than 6 wk
Atypical chronic leg pain (neg SLR)
New or progressive neuromotor deficit
Occupational medicine Difficult workers’ compensation situations
Disability/impairment ratings
Return to work issues
Rheumatology r/o inflammatory arthropathy
r/o fibrositis/fibromyalgia
Primary care sports medicine specialist Chronic back pain more than 6 wk
Chronic sciatica more than 6 wk
Recurrent back pain
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Prognosis
Long term course of LBP is variable
90% will regain function with decreasing pain after 6 weeks despite physician intervention
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.Summary of Treatments
Reassurance- prognosis is often good with most cases resolving with little intervention
Most commonly use treatment including activity modification, bed rest (short duration if at
all), conservative medications, progressive ROM and exercise, manipulative treatment
and patient education.
Use for first 4-6 weeks before adding additional diagnostic tests unless patients symptoms
worsen
Follow up is crucial to monitor progress and adjust treatment as tolerated
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261). McGraw-Hill.
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.htmlSuggested Approach to patient with
Acute and Chronic Low Back Pain
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP. https://www.aafp.org/afp/2015/0515/p708.htmlReferences
Casazza, B. A., MD. (2012). Diagnosis and Treatment of Acute Low Back Pain. AAFP. https://www.aafp.org/afp/2012/0215/p343.html
Das, J. M., & Nadi, M. (2020, May 24). Lasegue Sign. Https://Www.Ncbi.Nlm.Nih.Gov/Books/NBK545299/.
https://www.ncbi.nlm.nih.gov/books/NBK545299/
Dermatome. (2021). [Illustration]. https://www.ncbi.nlm.nih.gov/books/NBK535401/figure/article-29335.image.f1/
Herndon, C. M., PharmD, Schiel Zorberi, S., MD, & Gardener, B. J., MD. (2015). Common Questions about Chronic Low Back Pain. AAFP.
https://www.aafp.org/afp/2015/0515/p708.html
Herring, W. (2012). Learning Radiology Recognizing the Basics (2nd ed.). Elsevier.
Reversed Lasègue or Prone Knee Bending Test. (2016). Https://Www.Youtube.Com/Watch?V=4VxKyPRq6HA.
https://www.youtube.com/watch?v=4VxKyPRq6HA
Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mobsy’s Guide to Physical Examination (6th ed.). Elsevier
Straight Leg Raise or Lasègue’s Test for Lumbar Radiculopathy. (2016). Https://Www.Youtube.Com/Watch?V=LdAD9GNv8FI.
https://www.youtube.com/watch?v=LdAD9GNv8FI
The SLUMP Test. (2016). Https://Www.Youtube.Com/Watch?V=HFGfP84uwEo. https://www.youtube.com/watch?v=HFGfP84uwEo
Webb, C. W., DO, & O'Connor, F. G., MD. (2008). Low Back Pain. In Current Diagnosis and Treatment Family Medicine (2nd ed., pp. 249-261).
McGraw-Hill.
Will, J. S., DO, Bury, D. C., DO, & Miller, J. A., DPT. (2018). Mechanical Low Back Pain. AAFP. https://www.aafp.org/afp/2018/1001/p421.htmlYou can also read
