Back pain

Back pain affects an estimated 80% of the population; in fact, it's the second leading reason — after the common cold — for lost time from work. Although this symptom may herald a spondylogenic disorder, it may also result from a genitourinary, GI, cardiovascular, or neoplastic disorder. Postural imbalance associated with pregnancy may also cause back pain.

The onset, location, and distribution of pain and its response to activity and rest provide important clues about the cause. Pain may be acute or chronic, constant or intermittent. It may remain localized in the back or radiate along the spine or down one or both legs. Pain may be exacerbated by activity — usually bending, stooping, lifting, or exercising — and alleviated by rest, or it may be unaffected by either.

Intrinsic back pain results from muscle spasm, nerve root irritation, fracture, or a combination of these mechanisms. It usually occurs in the lower back, or lumbosacral area. Back pain may also be referred from the abdomen or flank, possibly signaling a life-threatening perforated ulcer, acute pancreatitis, or a dissecting abdominal aortic aneurysm.

Emergency interventions

If the patient reports acute, severe back pain, quickly take his vital signs, and then perform a rapid evaluation to rule out life-threatening causes. Ask him when the pain began. Can he relate it to any causes? For example, did the pain occur after eating? After falling on the ice? Have the patient describe the pain. Is it burning, stabbing, throbbing, or aching? Is it constant or intermittent? Does it radiate to the buttocks or legs? Does he have leg weakness? Does the pain seem to originate in the abdomen and radiate to the back? Has he had a pain like this before? What makes it better or worse? Is it affected by activity or rest? Is it worse in the morning or evening? Does it wake him up? Typically, visceral-referred back pain is unaffected by activity and rest. In contrast, spondylogenic-referred back pain worsens with activity and improves with rest. Pain of neoplastic origin is usually relieved by walking and worsens at night.

If the patient describes deep lumbar pain unaffected by activity, palpate for a pulsating epigastric mass. If this sign is present, suspect a dissecting abdominal aortic aneurysm. Withhold food and fluid in anticipation of emergency surgery. Prepare for I.V. fluid replacement and oxygen administration. Monitor the patient's vital signs and peripheral pulses closely.

If the patient describes severe epigastric pain that radiates through the abdomen to the back, assess him for absent bowel sounds and for abdominal rigidity and tenderness. If these occur, suspect a perforated ulcer or acute pancreatitis. Start an I.V. for fluids and drugs, administer oxygen, and insert a nasogastric tube while withholding food.

History and physical examination

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜" (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

Medical causes

❑ Abdominal aortic aneurysm (dissecting). Life-threatening dissection of this aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, however, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

❑ Ankylosing spondylitis. Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn't relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.

❑ Appendicitis. Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney's point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney's point), and rebound tenderness. Some patients also have painful, urgent urination.

❑ Cholecystitis. Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours, and patients usually have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right upper quadrant tenderness, abdominal rigidity, pallor, and sweating.

❑ Chordoma. A slow-developing malignant tumor, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumor expands, pain may be accompanied by constipation and bowel or bladder incontinence.

❑ Endometriosis. Endometriosis causes deep sacral pain and severe, cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It's accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.

❑ Intervertebral disk rupture. Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It's accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient's spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

❑ Lumbosacral sprain. Lumbosacral sprain causes aching, localized pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine intensifies pain, whereas rest helps relieve it. The pain worsens with movement and is relieved by rest.

❑ Metastatic tumors. Metastatic tumors commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscular pain (usually worse at night), and isn't relieved by rest.

❑ Myeloma. Back pain caused by myeloma, a primary malignant tumor, usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

❑ Pancreatitis (acute). Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about.

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. A late sign may be jaundice. Occurring as inflammation subsides, Turner's sign (ecchymosis of the abdomen or flank) or Cullen's sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

❑ Perforated ulcer. In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, the absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

❑ Prostate cancer. Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also produce hematuria and decrease the urine stream.

❑ Pyelonephritis (acute). Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

❑ Renal calculi.The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. Its intensity varies but may become excruciating if calculi travel down a ureter. If calculi are in the renal pelvis and calyces, dull and constant flank pain may occur. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover the calculi for analysis.

❑ Rift Valley fever. Rift Valley fever is a viral disease generally found in Africa, but recent outbreaks have occurred in Saudi Arabia and Yemen. It's transmitted to humans from the bite of an infected mosquito or from exposure to infected animals. Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

❑ Sacroiliac strain. Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or gluteus medius or abductor lurch.

❑ Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites of the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

❑ Spinal neoplasm (benign).Spinal neoplasm typically causes severe, localized back pain and scoliosis.

❑ Spinal stenosis. Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

❑ Spondylolisthesis. A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may be asymptomatic or may cause low back pain, with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.

❑ Transverse process fracture. Transverse process fracture causes severe localized back pain with muscle spasm and hematoma.

❑ Vertebral compression fracture. Initially, vertebral compression fracture may be painless. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

❑ Vertebral osteomyelitis. Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

❑ Vertebral osteoporosis. Vertebral osteoporosis causes chronic, aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.

Other causes

❑ Neurologic tests. Lumbar puncture and myelography can produce transient back pain.

Special considerations

Monitor the patient closely if the back pain suggests a life-threatening cause. Be alert for increasing pain, altered neurovascular status in the legs, loss of bowel or bladder control, altered vital signs, sweating, and cyanosis.

Until a tentative diagnosis is made, withhold analgesics, which may mask the symptoms of a life-threatening cause. Also withhold food and fluids in case surgery is necessary. Make the patient as comfortable as possible by elevating the head of the bed and placing a pillow under his knees. Encourage relaxation techniques such as deep breathing. Prepare the patient for a rectal or pelvic examination. He may also require routine blood tests, urinalysis, a computed tomography scan, appropriate biopsies, and X-rays of the chest, abdomen, and spine.

Fit the patient for a corset or lumbosacral support. Instruct him not to wear this in bed. He may also require heat or cold therapy, a backboard, a convoluted foam mattress, or pelvic traction. Explain these pain-relief measures to the patient. Teach him about alternatives to analgesic drug therapy, such as biofeedback and transcutaneous electrical nerve stimulation.

Be aware that back pain is notoriously associated with malingering. Refer the patient to other professionals, such as a physical therapist, an occupational therapist, or a psychologist, if indicated.

Pediatric pointers

Because a child may have difficulty describing back pain, be alert for nonverbal clues, such as wincing or a refusal to walk. Closely observe family dynamics during history taking for clues that suggest child abuse.

Back pain in the child may stem from intervertebral disk inflammation (diskitis), neoplasms, idiopathic juvenile osteoporosis, and spondylolisthesis. Disk herniation typically doesn't cause back pain. Scoliosis, a common disorder in adolescents, rarely causes back pain.

Geriatric pointers

Suspect metastatic cancer — especially of the prostate, colon, or breast — in older patients with a recent onset of back pain that usually isn't relieved by rest and worsens at night.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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