Low Back Pain/Swelling

Low back pain is the second most common cause of doctor visits in the U.S. and is the most common cause of disability. Up to 90% of the population will experience back pain during their lives. Studies show that, at any given time, up to 20% of the population is experiencing low back pain. Most cases are due to mild muscle injury; however, “red flags” should be evaluated to rule out more serious disease.

Differential Diagnosis

• Lumbosacral muscle strain
  –Most common etiology of low back pain
  –Most common cause of disability in adults <45 years old
  –Aggravated by movement, better with rest
• Lumbar disc herniation
  –Especially of L4-L5 and L5-S1
  –Usually with unilateral radiation down the leg in a dermatomal pattern
  –Increased pain with sitting
  • Spinal stenosis
    –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
    –Increased pain with standing
  • Sacral-iliac joint dysfunction
    –Especially in young, thin women or in pregnancy
    –Unilateral upper buttock pain, relieved with movement
  • Vertebral fracture
    –Often associated with trauma or osteoporosis
  • Spondylolisthesis
    –Especially in young athletes
  • Secondary gain (e.g., drug seeking, disability or liability issue)
  • Extraspinal causes (e.g., radiation from kidney stones)
  • Systemic causes (<1%)
    –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
    –Infection: Osteomyelitis, abscess
    –Abdominal aortic aneurysm
    –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
    –Cauda equina syndrome
    –Paget's disease

  Workup and Diagnosis

  • History and physical are the most important diagnostic tools
    –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
  • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
  • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
    –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
    –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
    –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
  • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study

  Treatment

  • In absence of red flag symptoms, return to activity as soon as possible; rest has not been shown to improve recovery
  • Acetaminophen, NSAIDs, opioids, and/or muscle relaxants for pain; epidural corticosteroid injections may be indicated for resistant pain
  • Patient education (weight loss, exercise, proper back biomechanics and ergonomics)
  • Physical therapy, including pain relief modalities (ice, heat, ultrasound), stretching, strengthening, aerobic conditioning, and relaxation therapy
  • Surgery may be indicated for refractory disease, large neurologic deficits, unbearable pain, or significant limitations
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Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Back burning sensation: Introduction (review 12 causes)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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