Medical Decision Making
Low Risk Back Pain
This patient presents with back pain most consistent with ***. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica.*** No back pain red flags on history or physical. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), cauda equina (no bowel or urinary incontinence/retention, no saddle anesthesia, no distal weakness), AAA, viscus perforation, pulmonary embolism, renal colic and pyelonephritis (afebrile, no CVAT, no urinary symptoms).
Given the clinical picture, no indication for imaging at this time.
*** Plan: pain control, supportive care, reassess
ICD 10 Codes
M54.5 – Low back pain, unspecified
- S39.012 – Low back strain
- M54.51 – Vertebrogenic low back pain
- M54.9 – Dorsalgia
- M54.59 – Other low back pain
- M54.6 – pain in thoracic spine
- M54.31 – Sciatica, right side
- M54.32 – Sciatica, left side
Back pain with Sciatica
- M54.41 -Lumbago with sciatica, right
- M54.42 -Lumbago with sciatica, left
ED Summary
You were evaluated today in the Emergency Department for back pain. Your evaluation did not show signs of a life-threatening medical condition.
Please schedule an appointment for follow-up with your primary care physician this week for further evaluation of your symptoms.
Return to the Emergency Department if you experience worsening back pain, difficulty walking, fevers, numbness, tingling, incontinence, or any other concerning symptoms.
Patient Education
Low back pain is very common. An estimated 75-85% of Americans experience some form of back pain during their life. Although low back pain can be quite debilitating and painful, in approximately 90% of cases, it is temporary and pain improves without surgery. However, 50% of patients who suffer from episodes of low back pain will have recurrent episodes within one year. Low back pain is considered to be chronic when it persists for more than 12 weeks.
Common Causes of Low Back Pain
There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
- Sprains & Strains – One of the more common causes of low back pain is muscle soreness from overactivity. Muscles and ligament fibers can be overstretched or injured.This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this stiffness and soreness in the low back and other areas of the body that usually goes away within a few days.
- Disk Injury
- Disk tear: Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain, whereas others have pain that lasts for weeks, months, and even years. Why some people have pain and others do not is not well understood.
- Disk herniation: a disk herniates when its jelly-like center (nucleus) pushes against its annulus. If the disk is very worn or injured, the nucleus may squeeze all the way through the annulus and place pressure on sensitive spinal nerves, causing pain. Herniatated disks in the lower back often put pressure on the sciatic nerve resulting in pain that radiates from the buttock down the leg. This is called sciatica. A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
- Disk Degeneration – With age, intervertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints — the small joints located between each vertebra on the back of the spine — to rub against one another. Pain and stiffness result. Smoking has also been found to accelerate disk degeneration.This wear and tear on the facet joints is referred to as osteoarthritis, also known as spondylosis. It can lead to further back problems, including spinal stenosis.
- Degenerative Spondylothesis – Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. Vertebrae can move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
- Spinal Stenosis – When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone (arthritis) in your facet joints to help support the vertebrae. Over time, this bone overgrowth (called spurs) can lead to a narrowing of the spinal canal, in turn putting pressure on the spinal cord and nerves. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
- Scoliosis – an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly weakness, or numbness in the legs if pressure on the nerves is involved.
- Compression Fracture – Vertebral compression fractures are a common cause of back pain in the elderly. As we get older, our bones become weaker and more likely to break, a condition called osteoporosis. In people with osteoporosis, minor trauma — such as sitting forcefully on a hard chair or toilet, or a gound-level fall — can cause bones in the spine to break, resulting in extreme back pain when moving.
Imaging Tests
- X-rays show broken bones, aging changes, curves, or deformities, but not disks, muscles, or nerves.
- Magnetic resonance imaging (MRI) scans show soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible on an MRI scan.
- Computerized axial tomography (CAT) scans focus on bones.
- Bone scan may be used to detect fractures or rare problems like cancer, infection.
- Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Medications
Several medications may be used to help relieve your pain.
- Acetaminophen can relieve pain with few side effects
- Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen reduce pain and swelling
- Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine
- Muscle relaxers like methocarbamol, carisoprodol, and cyclobenzaprine are another type of oral medication that can help. However, they can make you drowsy. So if you are taking muscle relaxers, do not drive or perform tasks that require you to be alert.
Physical medicine
Low back pain can be disabling. Medications and therapeutic treatments combined often provide enough relieve pain enough to enable you to do all the things you want to do.
- Physical therapy can include passive modalities like heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to the lower back can be very helpful in relieving pain.
- Braces are often used. The most common is a corset-type brace that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
- Chiropractic or manipulation therapy is available in many different forms. Some patients are able to get relief from their low back pain with these treatments.
- Traction is often used, but without scientific evidence for effectiveness.
- Other exercise-based programs, such as Pilates or yoga, are helpful for some patients.
Surgery
Surgery for low back pain should be considered only when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery. In addition, surgery should only be considered if your doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option. Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply cannot be treated with surgery.
- Spinal Fusion is an option when motion is the source of pain. Painful vertebrae are fused together so that they heal into a single, solid bone, which eliminates motion between the vertebral segments. For example, your doctor may recommend spinal fusion if you have spinal instability, a curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is that if the painful spine segments do not move, they should not hurt.The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
- Disk Replacement involves removing the disk and replacing it with an artificial disk. The goal is to allow the spinal segment to keep some flexibility and maintain more normal motion.
- Diskectomy involves removing the damaged portion of a hernited disk, in turn relieving pressure on the nerve, allowing sciatica to resolve.
- Laminectomy involves removing the thickened ligments and bone spurs that are compressing the nerves, in turn relieving pressure on the spinal canal, resulting in less nerve pain.
- Kyphoplasty/Vertebroplasty involves injecting cement into the broken bone to stabilize an osteoporotic compression fracture. This helps eliminate the sharp pain associated with the fracture.
Prevention
It may not be possible to prevent low back pain, because we cannot avoid the normal wear and tear on the spine that accompanies aging. However, there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
- Exercise Regularly – combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
- Use Proper Lifting Technique – be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
- Maintain a Healthy Weight – being overweight puts added stress on your lower back.
- Avoid Smoking – both the smoke and the nicotine cause your spine to age faster than normal.
- Use Proper Posture – good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
References
- Low Back Pain – American Association of Neurological Surgeons
- Low Back Pain – American Academy of Orthopedic Surgeons
- Lumbago/Sciatica –
