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Chapter 24 • Low Back Pain (Acute)
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FIGURE 24-1 Testing for lumbar nerve root compromise.
(From Bigos S, Bowyer OR, Braen GR, et al: Acute low
back problems in adults, clinical practice guidelines, Quick
Reference Guide Number 14, Rockville, Md., 1994, Department of Health and Human Services, U.S. Public
Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 95-0643.)
Nerve root
Pain
Numbness
L4 L5 S1
Motor
weakness
Screening
examination
Reflexes
and intervertebral disks. Trauma may be caused by
blunt impact, repetitive injury, or sudden stress caused
by lifting or pulling. Low back pain is the most common occupational injury reported, and so knowing a
patient’s occupation helps assess specic risk factors.
Injury to the back usually results in contusions and
abrasions but can also cause spinal fracture if the force
is major, such as that sustained in a motor vehicle accident or fall. In the elderly, an acute spinal fracture
might result from strenuous lifting when osteoporosis
is present. Most cases of ALBP in adolescents who are
athletically active are caused by injury to the posterior
structures of the spine.
Injury to the spinal column should be suspected
in anyone whose level of consciousness is impaired
after an accident. Cervical spine fractures are sustained
Extension of
quadriceps
Squat and rise Heel walking
Knee jerk
diminished
Dorsiflexion of
great toe and
foot
None reliable
Plantar flexion
of great toe
and foot
Walking on
toes
Ankle jerk
diminished
during exion, extension, compression, rotation, or a
combination of forces.
Systemic Disease, Cancer
Metabolic disease, inammatory disorders, and bromyalgia can lead to back pain. Patients with a history
of cancer may have increased risk of a spinal tumor.
Neuroblastoma is common in young children, and although it occurs in the abdomen, metastases to the
spine may produce back pain. People younger than
20 years and older than 50 years are at increased risk
for tumor, as are those with a history of cancer.
Age
In the absence of trauma, the sudden onset of severe low
or middle back pain in people older than 30 years might
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Chapter 24 • Low Back Pain (Acute)
suggest a dissecting aortic aneurysm; the pain is not alleviated by rest. Patients older than 50 years are at increased risk for compression fracture as well as cancer.
Bowel and Bladder Symptoms
Loss of urinary or stool continence indicates cauda
equina or S1-S2 nerve root compromise secondary to a
herniated disk, nerve root entrapment, spinal stenosis,
infection, or tumor. Constant lumbar puncture with
saddle anesthesia, urinary retention, and fecal incontinence are symptoms of cauda equina syndrome, which
is considered a surgical emergency.
Children are embarrassed to talk about urinary or
bowel habits and changes. Hidden spinal cord tumors
might have a relationship to developmental delays in
bladder and bowel control. Children under 4 years
of age who have back pain should be evaluated for
serious diseases, such as intraspinal tumors, dermoid
cysts, and malignant astrocytomas.
Medications
Long-term use of corticosteroids can lead to compression fractures of the vertebrae. Use of intravenous
drugs may suggest infection as a cause.
What does the location of pain tell me?
Key Question
l
Where does it hurt?
Location of Pain
In general, children are less specic than adults when
describing location of pain. Traumatic lesions are more
likely to occur in the cervical and lumbar portions of
the spine, where there is more motion and less protection. Generalized pain or pain over a fairly wide anatomical area is frequently seen with overuse problems
and inammatory conditions.
Sciatica pain is a sharp, burning pain that radiates
down the posterior and lateral leg to the foot or ankle.
Back pain with neck stiffness can indicate cervical osteomyelitis. Rheumatoid arthritis produces pain in the
upper back and neck. Localized pain is seen with spondylolysis and tumors. Flank pain in adults may indicate
a kidney infection. Pain from gallbladder disease radiates to the subscapular areas. Compression fractures of
vertebrae associated with osteoporosis or malignancy
may produce pain over the midthoracic area.
Children with traumatic low back derangement
will have pain and muscle spasm in the lumbar
area from the pressure and shock of an impact injury
collision.
What does the pattern of pain tell me?
Key Questions
l
When did the pain start?
l
How long have you had this pain?
l
What does the pain feel like?
l
Does it interfere with sleep?
l
Have you had this pain before?
Onset
The onset of ALBP is sudden, and more than half of
patients do not associate it with a specic precipitating
event or injury. The vast majority of cases of ALBP
resolve with conservative treatment in 4 weeks, and
radiographic or further diagnostic studies are not
recommended until then.
Children are frequently poor historians and parents
may have a difcult time remembering when the pain
started. Association with events such as birthdays,
holidays, and activities is helpful in establishing the
onset of a child’s pain. Pain that is mild and of short
duration (1 to 2 weeks) is rarely serious.
Back pain lasting longer than 4 weeks needs to be
reevaluated for further diagnostic studies.
Duration
Subacute back pain is of 6 to 12 weeks’ duration. Chronic
back pain is pain lasting for more than 3 months. In people
younger than 40 years of age, the cause may be postural,
related to weak abdominal or back muscles or may indicate congenital spinal deformity, such as scoliosis or ankylosing spondylitis. In older people, chronic back pain
is more likely to indicate degenerative disease, such as
spinal stenosis or disk herniation. In children, back pain
present for more than 3 weeks is often caused by organic
and serious causes.
Pain Characteristics
In children, expression of pain depends on the child’s
ability to put feelings of pain into behavior; observing
for these behaviors is important. Ask children to rate
the pain using a 10-point pain scale with happy to sad
faces (see Chapter 3). Ask adults to rate pain from 0
(no pain) to 10 (worst pain ever) and assess how
much the pain interferes with daily activities. Intractable back pain, especially night pain with constitutional ndings, is likely to indicate neoplastic disease. Painful scoliosis and stiffness are common
presenting symptoms of a spinal tumor. Hyperalgesia
is increased sensitivity to pain in damaged tissue;
this can develop after long-term use of opioids for
chronic pain.
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Night Pain
Nighttime back pain is a worrisome symptom that often signals a serious problem, such as tumor, infection,
or inammation. Generally, muscle strains, overuse
injuries, spondylolysis, spondylolisthesis, and Scheuermann disease (an exaggeration of the normal posterior
convex curvature of the thoracic spine) produce less
pain at night. Morning stiffness that improves as the
day progresses suggests ankylosing spondylitis.
Nighttime back pain is unusual and indicates the
need for a complete and thorough workup.
Recurring Pain
Back pain in young children who have had previous
injuries or fractures may be a symptom of child abuse.
In the older adult, it may be an indication of compression fractures of the spine. As with young children, it
may also signal abuse by a caregiver.
What does the pain in relation to activity tell me?
Key Questions
l
What makes the pain worse?
l
What makes the pain better?
l
School children: do you carry a backpack?
Aggravating Factors
Pain in the lumbar area after strenuous sporting activities is usually the result of trauma to the muscles and
tendons, causing contusions and sprain. It occurs when
the patient pushes the muscles and ligaments past the
normal level of tolerance. Repeated injury can cause
soft tissue scarring and shortening.
Stress and fatigue fractures of the pars interarticularis, the region between the superior and inferior articulating facets of the vertebra, occur when lumbar
lordosis places more stress on the pars, such as in gymnastics and tennis.
Pain that is aggravated by activity is usually musculoskeletal in origin. Pain of ankylosing spondylitis is
relieved with exercise. Spinal stenosis is associated
with increased pain with standing, sneezing, or coughing. In an active adult poor preparation before exercise
can lead to back injury and pain.
Any child who has voluntarily given up a pleasurable
activity because of back pain has a severe symptom.
Alleviating Factors
Back pain not associated with any activity and not relieved by rest may indicate tumor. In children, back
pain relieved with aspirin or nonsteroidal antiinammatory drugs may indicate an inammatory cause.
Pain that is alleviated by rest and heat indicates a musculoskeletal cause. Pain of spinal stenosis is relieved
by exion of the spine.
Suspect spondylolisthesis, or forward slippage of one
vertebra over another, if the onset of pain is during hyperextension, which can occur with a back handspring,
buttery stroke in swimming, or a tennis serve. The defect arises from a stress fracture or stress reaction of the
isthmus of the pars interarticularis in the area of L5-S1.
The pain localizes to the low back and occurs during a
growth spurt and after engaging in sporting events. The
pain improves with rest and is worse with standing.
Backpack
School children often carry heavy backpacks, increasing the risk of back pain and injury.
What does radiation of pain tell me?
Key Questions
l
Does the pain travel?
l
Can you show me where the pain travels?
Radiation of Pain
Referred pain is of two types: (1) pain referred from the
spine into areas lying within the lumbar and upper sacral
dermatomes; and (2) pain referred from the pelvic and
abdominal viscera to the spine. Pain from the upper lumbar spine usually radiates to the anterior aspects of the
thighs and legs, and pain from the lower lumbar spine radiates to the gluteal regions, posterior thighs, and calves.
Pain from visceral disease is usually felt within the
abdomen or anks. Gallbladder pain radiates around
the trunk to the right scapula. Position does not affect
the pain.
People with spondylolysis, a destruction of vertebral structure, or spondylolisthesis, an anterior displacement of a vertebra, report hamstring tightness and
buttock discomfort as well as low back pain.
Pain that is sharp and burning and radiates down the
lateral or posterior aspect of the leg to the lateral ankle or
foot is called sciatica and is a classic symptom of nerve
root irritation most often caused by disk displacement.
Are there signs of neurological damage?
Key Questions
l
Have you been stumbling?
l
Have you noticed any change in your balance or
coordination?
l
Does the child frequently stumble or fall?
l
Do you have numbness or tingling in your extremities?
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Chapter 24 • Low Back Pain (Acute)
Stumbling
Spinal cord tumors, such as astrocytoma or ependymoma, may present as a disturbance of movement,
posture, or strength in the spine or extremities. Impairment of proprioception or sensation from an upper
motor neuron lesion, exhibited by foot drop or ataxia,
may produce stumbling.
Numbness and Tingling
Radiculopathy (nerve root pain) is sharp pain felt in a
dermatomal pattern and is sometimes associated with
numbness and tingling.
Is there a family history of back pain?
Key Question
l
Does anyone in your family have scoliosis or a
crooked spine?
Family History
Spondylolysis and scoliosis are often seen in families,
with a 40% familial occurrence in Native Alaskans.
Could this pain be caused by systemic disease?
Key Question
l
Have you been ill?
Illness
Pharyngitis or upper respiratory tract infections, such
as pneumonia, can be the precursor to diskitis in children. The intervertebral disk in children receives its
blood supply from the surface of the adjacent vertebral bodies, providing the mechanism necessary for
infection. Uveitis and iritis may be associated with
juvenile rheumatoid arthritis or juvenile ankylosing
spondylitis.
A female patient with pelvic inammatory disease
may have mild to moderate dull, aching, lower abdominal, pelvic, or possibly back pain. With pyelonephritis, the patient may report fever, nausea and vomiting, headache, and back or ank pain. A urinary tract
infection may present as back pain.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Observe the Patient’s General Appearance
and Behavior
Any person appearing ill with a fever, limp, or unwillingness to walk is highly suspect for having an infectious
cause of back pain; however, a number of these symptoms may have a psychological component that should
be explored.
Observe for symmetry of posture and movement from
direct anterior, posterior, and lateral views of the patient.
Note the amount of thoracic kyphosis (anteroposterior
curve) and lumbar lordosis (anterior convexity) and the
alignment of the head and neck above the center of gravity. Children with diskitis often protect their backs by
sitting in a hyperextended position, using the arms as
support, and may lie down and cry if they are made to sit.
Observe Gait
Shifting or leaning to one side (listing) and atypical
scoliosis may indicate a tumor. Listing is caused by
asymmetric sustained muscle contraction. The spinal
curvature serves to relieve the discomfort and reduce
pressure on a nerve root.
Severely affected gait in spondylosis is caused by
hamstring tightness and results in uneven stride length
with a persistently xed knee to prevent hip exion,
which would stretch the tight hamstring muscles and
increase pain.
Assess Vital Signs
Fever may indicate systemic infection as well as diskitis. Unexplained weight loss may suggest neoplasm,
infection, or depression.
Examine Skin
Dermal cysts and/or a hairy patch over the spine may
indicate spinal anomaly or tumor.
A doughy, fatty mass in the midline of the back
(sometimes covered with hair [a Faun beard]) is evidence of a lipoma, which may extend into the spinal
cord and produce neurologic symptoms.
Examine Eyes, Ears, Nose, and Mouth
Uveitis iritis is seen in juvenile rheumatoid arthritis
and ankylosing spondylitis. Pharyngitis, otitis media,
or infection of hematogenous origin may be the cause
of diskitis in children.
Inspect the Back and Extremities
Observe for spinal alignment and symmetry of the tips
of the scapula, iliac crests, and gluteal crease. If indicated, measure and compare leg lengths from the anterosuperior iliac crest to the medial malleolus. Measurements can be performed with the patient standing
or supine. Legs should be of equal length or have less
than 1 cm difference in length. Leg length differences
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are associated with pathologic conditions of the sacroiliac, facet joint, and disk.
From posterior and lateral viewpoints, observe the
patient bending forward with feet together to detect
scoliosis, kyphosis, or stiffness and guarding.
Percuss and Palpate Back and Spine
Painful scoliosis and stiffness are common in osteoid
osteoma. Idiopathic scoliosis is usually painless without functional limitation. Point tenderness over the affected area is a nding associated with a compression
fracture of the vertebrae or an infection of the spine.
Palpate and percuss the back to determine if tenderness is in the paravertebral muscular or midline
spinous processes, which may indicate diskitis in
children or osteomyelitis. To rule out the sacroiliac
joint as the site of origin of ALBP, conduct a FABER
test (Figure 24-2). Place the patient in the supine position. Flex the leg and put the foot of the tested leg
on the opposite knee. The motion is that of Flexion,
Abduction, External Rotation at the hip. Slowly press
down on the superior aspect of the tested knee joint
lowering the leg into further abduction. The test is
positive if there is pain at the hip or sacral joint, or if
the leg cannot lower to the point of being parallel to
the opposite leg.
Use st percussion over the costovertebral angles
to discriminate ank pain caused by renal disease
from spinal pathology. Apply st percussion over the
costovertebral angles and over the spine to localize
tenderness.
Perform Range of Motion of the Spine
Ask the patient to ex, extend, rotate, and bend the
spine laterally. Decreased mobility and back pain along
the spine may indicate muscle spasm, neoplasm, or
bony deformity. Pain with forward exion usually
indicates a mechanical cause. Back extension pain
increases with spinal stenosis.
Look for compensating effects of hip motion on the
spine. The absence of lumbar exion may be totally
masked by a normal range of hip exion when the patient bends forward. Test lumbar exion by placing a
mark over the fourth lumbar vertebra and another over
the sacrum. Lumbar exion is demonstrated by an
increased distance between these two marks when
the patient bends forward.
A modied Schober test can be used to assess lumbar mobility. With the patient standing erect and heels
together, draw a mark on the skin 5 cm below an
imaginary line between the buttock dimples overlying
the posterior superior iliac spine. A second mark is
made 15 cm above this line. Then have the patient bend
forward touching their toes. An increase in distance
between these lines of 6 cm or more is normal; less
than 6 cm indicates decreased lumbar spine mobility
(Figure 24-3).
Observe for limitation of motion on forward bending caused by hip exion contracture. Lumbar lordosis
does not atten with forward bending and is an organic cause for back pain. In children, Scheuermann
disease, an exaggeration of the normal posterior convex curvature of the thoracic spine, produces pain
with forward exion, and spondylolysis produces pain
with hyperextension.
FIGURE 24-2 The FABER maneuver (Flexion, Abduction, External
Rotation at the hip). (From Cummings N, Stanley-Green S, Huggs
P: Perspectives in athletic training, St. Louis, 2009, Mosby.)
Perform Straight Leg Raising
The straight leg raising (SLR) test can assess sciatic
(L5 and S1) nerve root tension. With the patient supine, place one hand above the knee, the other cupping
the heel, and slowly raise the limb. Instruct the patient
to say when to stop because of pain. Observe for pelvic
movement and the degree of leg elevation when the
patient tells you to stop. Ask the patient to tell you the
most distal point of pain sensation, such as the back,
hip, thigh, or knee. While holding the leg at the limit of
elevation, dorsiexing the ankle and internally rotating
will add tension to the neural structures and increase
the pain if nerve root tension is present.
Pain below the knee at less than 70 degrees of elevation that is aggravated by dorsiexing the ankle or
hip rotation is a sign of L5 or S1 nerve root tension,
suggestive of a herniated disk. This test can also be
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Chapter 24 • Low Back Pain (Acute)
Modified Schober test (normal: total > 20 cm)
15 cm
5 cm
S2
10 cm
5 cm
S2
A
FIGURE 24-3 Performing the modified Schober test for spinal flexibility. (From Lawry G, Kreder H, Hawker G,
Jerome D: Fam’s musculoskeletal examination and joint injection techniques, ed. 2, Philadelphia, 2011, Mosby.)
performed with the patient sitting. In a positive test, the
patient will resist extension or will compensate with
hyperextension of the spine.
Lift each leg in succession to detect contralateral
pain in patients with nerve root compression.
Results of the SLR test in children with a tumor can
be unremarkable.
Check Hip Mobility
With the patient prone and supine, check active hip
exion, extension, internal and external rotation, and
strength against resistance. Weakness of the gluteus
maximus is associated with lumbar or referred pain
from L5 nerve roots or gluteal nerve injury. In small
children, check for congenital hip dysplasia with the
child supine and abducting the hips (see Chapter 22).
The knees should appear of equal height and should
rotate externally by equal degrees. The presence of a
hip click, joint instability, uneven hip-to-knee length
with hips and knees exed, and uneven gluteal skinfolds suggests congenital hip dislocation.
Finger-to-floor
distance
B
Flexion
malleus (claw toes), may aggravate misalignment of
back structures because of asymmetry.
Evaluate Muscle Strength
Evaluate strength against resistance of the lower extremity muscle groups. Test the patient’s ability to
stand on the toes and heels and to squat. A person with
S1 nerve root involvement may have little motor weakness but may demonstrate difculty in toe walking.
Difculty with heel walking or squatting indicates
involvement of L5 and L4 nerve roots. Leg extension
at the knee against resistance tests L4 root function.
In young children who are unable to cooperate for
measurement of muscle strength, use measurements
of similar limb girths as an estimate of the bilateral
symmetry of muscle strength.
Measure Muscle Circumference
Differences in muscle circumference greater than 2 cm
in two opposite limbs may signify atrophy secondary
to neurological impairment.
Examine Feet
Perform active range of motion of the ankle, feet, and
toes against resistance. Weakness, pain, or limitation of
dorsiexion movement indicates an L4 nerve root injury. Similar symptoms produced by plantar exion
indicate S1 and/or S2 involvement. Deformities of the
foot, such as talipes equinovarus (clubfoot) or hallux
Test Sensory Function
Neurological test results are evaluated by comparing
the symmetry of responses or perceptions. Bilateral
comparison is the simplest, most efcient way to determine the presence, location, and extent of any abnormality. A sensory examination is a general guide in
determining the level of spinal cord involvement. Test
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for light touch and pain sensation in the sensory areas
of L3-S1 dermatomes (see Figure 24-1). Dermatomes
overlap and vary greatly in individuals; thus only gross
changes can be detected by pinprick. Test 5 to 10 pinpricks in each dermatomal area if the patient reports
numbness and tingling. Disk lesions rarely produce
bilateral symptoms. It is sometimes difcult to distinguish numbness from a cutaneous nerve versus a dermatomal origin. Numbness from cutaneous nerve lesions does not occur in a dermatomal pattern. Numbness
and tingling are uncommon symptoms in most children
with back pain. When these symptoms are present, it
suggests a serious problem.
Assess Deep Tendon Reflexes
Normal deep tendon reexes (DTRs) are symmetrical.
DTRs are increased when an upper motor neuron lesion is present and decreased with a lower motor neuron lesion. A positive Babinski sign indicates a disorder of upper motor neurons affecting the motor area of
the brain or corticospinal tracts caused by spinal tumors or demyelinating disease. DTRs are decreased if
a tumor is pressing on a peripheral nerve. Asymmetric
abdominal reexes are seen in tumors of the spine.
An absent or a decreased ankle jerk reex suggests
an S1 nerve root lesion. An L3-L4 disk herniation is the
most common cause of a diminished knee-jerk reex.
EVIDENCE-BASED PRACTICE
How Important Is Obtaining
Radiographic Imaging When
Managing Acute Low Back Pain?
A systematic review and meta-analysis was conducted to
compare care with and without immediate routine lumbar
imaging for ALBP without indications of serious underlying
conditions. Outcomes examined included pain, function,
mental health, quality of life, patient satisfaction, and overall
patient improvement. Results showed no differences in
short-term or long-term follow-up between the group that
underwent imaging and the group that did not. In addition to
no clinical benefit from immediate imaging with ALBP, routine lumbar imaging is associated with radiation exposure
and increased cost related to unnecessary procedures.
Data from Andersen JC: Is immediate imaging important in managing
low back pain? J Athl Train 46:99, 2011.
Standing Anteroposterior and Lateral Views
of the Spine
These views of the spine accentuate any deformity,
such as scoliosis, and demonstrate vertebral integrity.
Oblique and Flexion Views of the Spine
These views increase the sensitivity for determining
instability.
Palpate the Abdomen
The abdomen is palpated to detect possible visceral
causes of back pain. In adults older than 50 years, a
ruptured aortic aneurysm can cause acute, severe, midthoracic back pain. If an aortic aneurysm is suspected,
immediate surgical referral is critical.
Check Rectal Sphincter Tone
In cauda equina syndrome, the compression of S1-S2
nerve roots results in decreased sphincter tone and decreased sensation in the perianal area. This syndrome
is a surgical emergency.
LABORATORY AND DIAGNOSTIC STUDIES
According to national practice guidelines, no diagnostic
tests are warranted within the rst 4 weeks for onset of
ALBP without neurological signs.
Plain Radiographs
Radiographs are useful in localizing the area of discomfort and ruling out fracture, tumor, osteophytes
(bone spurs), or vertebral infection.
Spine Radiograph
A at lumbosacral spinal radiograph is obtained when
there is a history of trauma or in people older than
50 years who have ALBP with signs of neurological
decit. Older people may have a history of straining or
lifting.
Bone Scan
Bone scanning is a radioisotope technique used to
assess blood ow and bone formation or destruction. It
can reveal inammatory and inltrative processes and
occult fractures. The distal wrist and lumbosacral spine
can be scanned to assess bone mineral density and the
risk of osteoporosis.
Electromyography
Electromyography (EMG) is performed to assess the
extent of nerve root compression and function of the
peripheral nerves.
Diagnostic Imaging
Magnetic resonance imaging (MRI) is useful in evaluating soft tissue detail, such as disk herniations, tumors,
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Chapter 24 • Low Back Pain (Acute)
and spinal cord pathologies, especially in vertebral osteomyelitis. Computed tomography (CT) is usually
used for bone visualization.
Urinalysis
Urinalysis is performed to assess kidney and metabolic
function, including infectious processes, to rule out
a visceral cause of back pain, such as the pain of
pyelonephritis.
Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate (ESR) will be
elevated in about 90% of patients with a serious musculoskeletal infection; however, there is no direct
relationship between ESR and severity of infection.
The test is nonspecic.
Complete Blood Count
The complete blood count (CBC) will detect anemia as
well as other conditions that might manifest as back
pain, such as tumor or infection. The anemia of chronic
disease is usually hypochromic or normochromic with
low iron indices.
DIFFERENTIAL DIAGNOSIS
Potentially Serious Causes of
Acute Low Back Pain
Spinal Fracture
The patient may relate a history of major trauma to the
back from an impact or fall or, if elderly, a history of
strenuous lifting or a minor fall. Pain is felt near the
site of injury. Any suspicion of spinal fracture should
be treated as an emergency. The patient is immobilized
to prevent further damage and transported by emergency personnel to obtain radiographs of the suspected
area of fracture.
Tumor (Osteoblastoma, Spinal Metastasis,
Osteoid Osteoma)
Primary tumors are a more common cause of back pain
in children; whereas metastases are a more common
cause in adults. The lower thoracic and upper lumbar
vertebrae are the most common sites of bony metastatic
disease from marrow tumors. A health history and diagnostic tests may reveal other signs of poor general health,
such as weight loss, fatigue, weakness, and anemia.
Infection (Osteomyelitis, Diskitis)
The spine is the most common site of osteomyelitis in
adults, secondary to adjacent infection or following
invasive instrumentation that results in bacterial seeding of the bone via arterial blood. Staphylococcus
aureus is the most frequently identied organism. Vertebral osteomyelitis causes stiffness and pain, usually
localized over the site of infection. A tender spinous
process, positive SLR test, and paravertebral muscle
spasm may be seen in vertebral osteomyelitis or septic
diskitis. Patients may have hip pain secondary to involvement of L2-S1.
Diskitis is usually a benign disorder in children that
results in intervertebral disk inammation. Children
will be reluctant to walk, sit, or stand. Pain will be aggravated by motion and relieved by rest. History will
reveal a recent bacterial infection, often secondary to
pharyngitis or otitis media, intravenous drug use, diabetes mellitus, or immunosuppression. A small percentage
of adults will report an acute onset of fever, weight loss,
and general malaise; however, the majority will only
have the symptom of back pain, present from 2 weeks
to years.
Herniated Disk
Disk herniation causes nerve root irritation and produces ALBP that radiates down the buttock to below
the knee. Pain is the prominent symptom, with numbness and weakness less common. Physical examination
will reveal a positive SLR test. If the pain persists longer than 1 month, magnetic resonance imaging or
electromyography is indicated.
Cauda Equina Syndrome
Compression of the S1 nerve root produces constant
back pain with saddle distribution anesthesia (buttock and medial and posterior thighs), fecal incontinence, bladder dysfunction, motor weakness of the
lower limbs, and radiculopathy. The patient may
limp and guard lumbar spine movement, will not be
able to heel walk or toe walk, and will have abnormal
or asymmetrical knee and ankle DTRs. The SLR
test will be positive. This syndrome is a surgical
emergency.
Sciatic Problems
Sciatica
The most common cause of sciatica is herniated disk.
History may disclose repetitive motion strain or strenuous lifting, twisting, and bending. ALBP is associated
with pain and burning that radiates along the lateral
thigh, leg, and foot, sometimes associated with numbness along the dermatomal areas. SLR and sitting knee
extension produce radicular pain below the knee at less
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than 60 degrees of limb elevation, and pain may be felt
in the buttocks or posterior thigh. Bowel and bladder
functions are normal.
Nonspecific Back Problems
Musculoskeletal Strain (Postural, Overuse)
Back structures such as muscles and ligaments can
become inamed from overuse or strain. History often
reveals no precipitating event for the onset of pain.
Patients may report that pain is alleviated by rest, especially in the supine position with hips and knees exed,
and by the application of heat or cold. Pain is aggravated by sitting, walking, standing, and with certain
motions. On physical examination, palpation will localize the pain, and muscle spasms may be felt. Range
of motion of the spine will increase the pain, especially
with forward exion. Neurological examination shows
no abnormalities.
Spondylolisthesis
Pain can be the result of disruption of the vertebral
spinous process, where the disruption results in subluxation of the vertebral body onto adjacent structures.
This usually occurs between L5 and S1. Pain is usually
chronic. Examination of the spine may disclose a palpable, prominent spinous process. Forward exion
may be limited.
Scheuermann Disease
Adolescent males develop this disease as a result
of anterior disk protrusion, causing wedging of the
thoracic vertebrae and exaggeration of the normal
posterior convex curvature of the thoracic spine. The
cause is unknown but may develop from excessive
lifting or spinal exion. The patient reports mild to
moderate pain, worsening toward the end of the day
or after physical activity but relieved by rest. Physi-
cal examination demonstrates an increase in thoracic
kyphosis on lateral view, made sharper by forward
bending.
Osteoporosis
Osteoporosis is loss of mineralized bone mass that
can result in a compression fracture of the vertebral
body, usually occurring in the thoracic area. Back
pain is often chronic and poorly localized. Multiple
compression fractures may produce dorsal kyphosis
and cervical lordosis. People at greatest risk are post-
menopausal white women, especially those with a
slight build and a history of physical inactivity. It is
also common in people older than 70 years who have
age-related reduction in vitamin D synthesis. Osteo-
porosis can also be secondary to endocrine imbalance
(such as hyperthyroidism), organ disease, drugs (such
as corticosteroids), or excessive intake of alcohol.
Ankylosing Spondylitis
Ankylosing spondylitis is a systemic inammatory
condition of the vertebral column and sacroiliac joints.
Peak incidence is in people 20 to 30 years old; males
are most often affected. Patients report chronic LBP,
which is worse on morning rising and lessens as the
day progresses. Examination shows an excessive thoracic kyphosis and rounding of the posterior thoracic
spine with forward exion of the head, neck, and lower
back. About 30% of patients will have arthritis of other
joints. Radiographs may reveal fusion of vertebrae,
and ESR is elevated.
Spinal Stenosis
Spinal stenosis is a bony encroachment on the nerve
roots of the lumbar spine and is the most common
cause of ALBP in adults older than 50 years. Patients
report ALBP associated with lumbosacral radiculopathy, pain with walking or standing, and pain relief with
sitting or forward exion of the spine. Neurogenic
(pseudo) claudication pain of the lower extremities is
made worse with prolonged standing, walking, bending, or hyperextending the back.
Nonspinal Causes
Aortic Aneurysm (Dissecting)
Sudden onset of severe low or middle back pain that is
not alleviated by rest in people older than 30 years
might suggest a dissecting aortic aneurysm. The patient
may exhibit pallor, diaphoresis, and confusion. Pulses
and blood pressure measured on each upper extremity
will be asymmetric. Emergency surgery is indicated.
Gallstones
Gallbladder problems increase with age. A gallbladder
attack often follows a fatty meal. Crampy right upper
quadrant (RUQ) pain following a fatty meal is pro-
duced by spasms of the cystic duct that is obstructed
with a stone. Gallbladder pain radiates around the
trunk to the right scapula. Position does not affect the
pain. Patients report belching and bloating. Attacks
may increase in frequency and severity and cause
nighttime wakening. During an attack, palpation will
show RUQ tenderness. Physical ndings between
attacks may be normal or there may be tenderness to
palpation of the RUQ on inspiration (Murphy sign) if
the gallbladder is inamed. An RUQ mass may be felt
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Chapter 24 • Low Back Pain (Acute)
if the gallbladder is obstructed. Obstruction is an emergency surgical situation.
Pyelonephritis
With pyelonephritis, the patient will appear ill and diaphoretic and may report nausea and vomiting, headache, and back or ank pain. The patient may have a
fever. Severe lumbar tenderness will be found on st
percussion for costovertebral angle (CVA) tenderness.
Urinalysis will show cloudy, malodorous urine, and
microscopy will show casts and cells (i.e., red blood
cells, white blood cells, and epithelial cells).
Pleuritis
Inammation of the pleural lining of the lungs often
follows an upper respiratory tract infection. Pleuritic
pain is sharp, worsens on inspiration or with coughing,
and is lessened by lying on the affected side. Physical
examination of the lungs may be normal, or crackles
and bronchial breath sounds will be heard on auscultation. A chest radiograph will provide information on
the condition of the lungs.
Pelvic Inflammatory Disease
The symptoms of pelvic inammatory disease (PID)
depend on the extent of infection. Infection usually
begins in the lower urinary tract or cervix and
spreads to the endometrium, Fallopian tubes, and
peritoneum. The sexually active female patient may
have mild to moderate dull, aching, lower abdominal, pelvic, or possibly back pain. She will report
tenderness during cervical motion, uterine motion, or
palpation of the adnexa. History may be positive for
sexually transmitted infections (usually Neisseria
gonorrhoeae or Chlamydia trachomatis), vaginal
symptoms, or use of an intrauterine device for contraception.
Psychogenic Causes
Psychologic Back Pain
A careful history is needed to gain insight into the
psychosocial and economic issues surrounding
report of back pain. The patient may have a history
of recent life stressors, be involved in a legal injury
or workers’ compensation action, or have a history
of depression or alcohol abuse. The clinician should
be aware of exaggerated signs of pain, such as
moaning, grimacing, or overreacting. A malingerer
pretends to suffer, but when distracted will show
inconsistent and variable results on examination
such as SLR, or will describe radiation of pain inconsistent with dermatome distribution.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
POTENTIALLY SERIOUS CAUSES
Spinal fracture Trauma to spine or back; pain is felt
Tumor History of cancer; progressive pain is
Osteoblastoma Neck or back pain not relieved by
Osteoid
osteoma
Common Causes of Acute Low Back Pain
near site of injury
unremitting; occurs at night and at
rest
aspirin; occurs in older adolescents
and young adults
Occurs primarily in adolescents; rare
in patients older than age 40; welllocalized pain that may be more severe at night and relieved by aspirin
or other prostaglandin inhibitors
Palpable tenderness over site
of fracture
Weight loss, fever, tenderness
near tumor
Localized tenderness; may
have scoliosis with muscle
pain
Painful, well-localized scoliosis
may be present
Considered an emer-
gency; immobilize
patient and transport for radiographs
ESR; bone scan
Plain film shows an
expansive osteolytic
lesion surrounded
by thin peripheral
rim of bone; bone
scan; CT scan
Bone scan
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