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Back Pain, Low

Basics

  • Common complaint in primary and acute care.
  • Defined as pain between costal margins and inferior gluteal folds.
  • Annual incidence ~7% in US; prevalence peaks at 28-42% in ages 40-69.
  • Leading cause of disability and productivity loss worldwide.

Etiology & Pathophysiology

  • Mechanical (facet arthropathy, myofascial, sacroiliac dysfunction)
  • Inflammatory (spondyloarthropathies)
  • Neuropathic/radicular (16-55% of chronic cases)
  • Herniated disc, spinal stenosis common causes
  • Nociplastic pain (central sensitization)

Risk Factors

  • Age, high-risk physical activities (lifting, twisting)
  • Obesity, sedentary lifestyle, smoking
  • Psychosocial factors: anxiety, depression, stress
  • Poor flexibility

Diagnosis

History

  • Onset: sudden or gradual
  • Inciting trauma or event
  • Pain characteristics and radiation (dermatomal for nerve root involvement)
  • Red flags: cancer, trauma, infection signs, neurologic symptoms, bowel/bladder dysfunction, immunosuppression

Physical Exam

  • Use IPASS approach (Inspection, Palpation, Active/passive ROM, Strength, Special tests)
  • Posture, gait, atrophy, tenderness midline/paraspinal
  • Lumbar spine ROM
  • Reflexes, strength, sensation assessment
  • Special tests:
  • Slump test (nerve root tension)
  • Straight leg raise (radiculopathy)
  • Stork test (spondylolisthesis vs facet OA)
  • Anal wink and saddle anesthesia for cauda equina
  • Hip tests (FABER, FADIR) for differentiation

Differential Diagnosis

  • Spine: fracture, disc herniation, stenosis, spondylolysis, spondylolisthesis, spondylosis
  • Systemic: infection, malignancy, inflammatory disorders
  • Referred: abdominal aortic aneurysm, herpes zoster, pelvic/retroperitoneal pathology

Diagnostic Tests

  • Primarily clinical diagnosis.
  • Imaging reserved for red flags or chronic/progressive symptoms.
  • MRI for chronic LBP or pre-surgical evaluation.
  • X-ray for fractures, spondylolysis, or spondylolisthesis.
  • Labs for suspected inflammatory or infectious causes.

Treatment

General Measures

  • Biopsychosocial multidisciplinary approach
  • Activity modification and early return to function
  • Physical therapy as first-line nonpharmacologic treatment

Medications

  • First line: NSAIDs if no contraindications
  • Second line:
  • Opioids (rare, lowest dose and shortest duration)
  • TCAs, SSRIs, SNRIs for neuropathic and mental health comorbidities
  • Gabapentinoids for chronic neuropathic symptoms

Referral

  • Osteopathic manipulative therapy, massage, chiropractic for refractory cases
  • Psychological evaluation and treatment
  • PM&R for epidural steroids or radiofrequency denervation with radicular symptoms
  • Neurosurgery/orthopedics for alarm symptoms or failed conservative care

Additional Therapies

  • No strong evidence for bracing, ultrasound, traction, or insoles
  • Osteopathic manipulation helpful in nonspecific and chronic LBP
  • Acupuncture, dry needling, meditation lack strong supporting evidence

Ongoing Care

  • Follow-up 2-4 weeks after acute flare; 6-12 weeks for chronic LBP
  • Monitor functional status and symptom progression

Patient Education

  • Avoid unnecessary imaging if no red flags
  • Encourage physical activity and adherence to therapy
  • Educate on recognition of alarm symptoms warranting further evaluation

Prognosis

  • Variable, often favorable with appropriate conservative management
  • Early intervention may prevent chronicity

Clinical Pearls

  • Imaging not beneficial initially without red flags
  • Conservative management with PT and NSAIDs effective
  • Surgical referral reserved for progressive neurologic deficits or structural pathology