Back pain
Back pain affects an estimated 80% of the population and is the second leading cause of absence from work. Although this symptom may indicate 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 back pain and its responses to activity and rest provide important clues about the cause. Back 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. Back pain may be exacerbated by activity — typically by bending, stooping, or lifting — 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; such referred pain can signal such life-threatening conditions as a perforated ulcer, acute pancreatitis, or a dissecting abdominal aortic aneurysm. Back pain in the scapular area may reflect referred cardiac pain, such as that seen in myocardial infarction, another life-threatening condition.
Assessment
History
Ask the patient where the pain is located; back pain in some areas can signal the presence of a life-threatening condition.
Act Now: If the patient reports acute, severe back pain, quickly obtain his vital signs and perform a rapid evaluation to rule out life-threatening causes. If he describes deep lumbar pain unaffected by activity, observe for a pulsating epigastric mass. Presence of this sign may indicate a dissecting abdominal aortic aneurysm. Withhold food and fluids because the patient may require emergency surgery. Prepare for I.V. fluid replacement and oxygen administration.
If he reports severe epigastric pain that radiates through the abdomen to the back, assess for absent bowel sounds and abdominal rigidity and tenderness. These symptoms may indicate a perforated ulcer or acute pancreatitis. Start an I.V. line for fluids and medications, administer oxygen, insert a nasogastric tube, and withhold food.
If the patient complains of scapular area back pain, especially if accompanied by shortness of breath or diaphoresis, give oxygen via a nasal cannula or mask and obtain a 12-lead electrocardiogram to rule out myocardial infarction.
After you have ruled out potential life-threatening causes of back pain, continue to obtain the patient’s history. Observe him for expressions of pain while gathering information. Ask about previous injuries and illnesses, dietary habits, alcohol intake, and cigarette smoking. Inquire about medications, including past and present prescriptions, use of over-the-counter drugs, and disease processes or pain control regimens.
Ask the patient about the onset of his back pain. Were there precipitating factors? Ask the patient to rate the pain on a standardized pain scale. Ask him for details about the pain — is it burning, stabbing, throbbing, or aching? Constant or intermittent? If it’s intermittent, does it occur at a specific time of day? Does the pain radiate? Is there associated weakness? Does he experience repetitive pain or different types of pain? What, if anything, lessens the pain? What aggravates it? The patient’s answers will help identify the cause of his back pain. For example, visceral referred back pain is indicated if the patient states that the pain isn’t affected by activity and rest. In contrast, spondylogenic-referred back pain is likely if the pain increases with activity and decreases with rest. Pain of neoplastic origin is indicated if the patient reports that he can obtain relief by walking and that the pain increases at night.
Physical examination
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 the patient about unusual sensations in the legs, such as numbness and tingling. If pain doesn’t prevent standing, observe the patient’s posture — does he stand erect or 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 (stand close by during these tests so that you can assist the patient if he falls). 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. (See How to elicit Babinski’s reflex.) Evaluate the strength of the extensor hallucis longus by asking the patient to keep his great toe firmly in place 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, assist the patient into 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.
Note the range of motion of the hip and knee. Palpate the flanks and percuss with your fingertips or fist to reveal the presence of costovertebral angle (CVA) tenderness.
Pediatric pointers
Because a child may have difficulty describing back pain, stay alert for nonverbal clues, such as wincing or a refusal to walk.
Back pain in children 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.
While obtaining the child’s history, pay close attention to family dynamics, noting factors that suggest child abuse.
Geriatric pointers
Suspect metastatic cancer — especially of the prostate, colon, or breast — in elderly patients with recent onset of back pain that worsens at night and isn’t usually relieved by rest. Remember that assessing back pain may be hampered in elderly patients with functional disabilities.
Medical causes
Abdominal aortic aneurysm (dissecting)
Life-threatening dissection of an abdominal aortic 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; pulsation ceases if rupture occurs. Aneurysmal dissection can also cause mottled skin below the waist, absence of femoral and pedal pulses, mild to moderate tenderness with guarding, and abdominal rigidity. Blood pressure in the patient’s legs may be lower than blood pressure in his arms. Signs of shock, such as cool, clammy skin, occur with significant blood loss.
Ankylosing spondylitis
Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain that 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; it isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. Ankylosing spondylitis can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.
Appendicitis
Appendicitis is a life-threatening disorder in which vague and dull discomfort in the epigastric or umbilical region gradually localizes in McBurney’s point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The localization of the 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 report painful, urgent urination.
Cholecystitis
Cholecystitis produces severe pain that occurs in the right upper quadrant of the abdomen and may radiate to the right shoulder, chest, or back. The pain may occur abruptly or gradually, increasing over several hours. Patients typically report a history of similar pain after consuming high-fat meals. 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
Disk rupture produces gradual or abrupt lower 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. It’s exacerbated by activity, coughing, and sneezing and lessened by rest. Accompanying symptoms include 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
Aching, localized pain and tenderness due to muscle spasm on lateral motion is the primary symptom of a lumbosacral sprain. The recumbent patient typically flexes his knees and hips to ease pain. Flexion of the spine intensifies pain, whereas rest facilitates relief.
Metastatic tumors
The spread of metastatic tumors to the spine — a common occurrence — leads to low back pain in approximately 25% of patients. It typically begins abruptly and is accompanied by cramping muscular pain. This pain is 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)
Acute pancreatitis is a life-threatening disorder that typically produces fulminating, continuous upper abdominal pain that may radiate to both flanks and the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly.
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. Jaundice may be a late sign. 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, absent 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, although hematuria and decreased urine stream may also occur.
Pyelonephritis (acute)
Acute pyelonephritis produces back pain or tenderness (especially over the CVA) as well as progressive pain in the flank and lower abdomen. Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.
Reiter’s syndrome
In some patients, sacroiliac pain is the first sign of Reiter’s syndrome. Pain is accompanied by the classic triad of conjunctivitis, urethritis, and arthritis.
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 CVA to the flank, suprapubic region, and external genitalia. Its intensity varies; it may become excruciating if calculi travel down a ureter. Calculi in the renal pelvis and calyces result in dull and constant flank pain. 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
Typical signs and symptoms of Rift Valley fever — a viral disease — include back pain, fever, myalgia, weakness, and dizziness. It may present as several different clinical syndromes. A small percentage of patients may develop encephalitis or hemorrhagic fever leading to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss. Although Rift Valley fever is typically found in Africa, outbreaks have also occurred in Saudi Arabia and Yemen. The disease is transmitted to humans through the bite of an infected mosquito or exposure to infected animals.
Sacroiliac strain
Sacroiliac strain causes 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 a gluteus medius or abductor lurch.
Smallpox (variola major)
Worldwide eradication of smallpox was achieved in 1977. The United States and Russia have the only documented storage sites of the virus, which is considered a potential agent for biological warfare. Initial signs and symptoms of smallpox include back pain, high fever, malaise, prostration, severe headache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and, later, pustular. The lesions, which develop simultaneously rather than gradually increasing in number, occur more frequently on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust. 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
).This neoplasm typically causes severe, localized back pain and scoliosis.
Spinal stenosis
Resembling a ruptured intervertebral disk, spinal stenosis produces back pain that may be accompanied by sciatica, commonly affecting 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
This injury causes severe, localized back pain with muscle spasm and hematoma.
Vertebral compression fracture
Initially, a 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’s 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.
Nursing considerations
Monitor the patient closely if the type and location of back pain suggest a life-threatening cause. Stay 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 to avoid masking symptoms. Withhold food and fluids until it’s determined whether the patient requires surgery. Once a medical emergency is ruled out, make him as comfortable as possible by elevating the head of the bed, placing a pillow under his knees, and administering pain medications. Prepare the patient for a rectal or pelvic examination, routine blood tests, urinalysis, computed tomography scan, biopsies, and X-rays of the chest, abdomen, and spine.
Fit the patient for a corset or lumbosacral support. Refer him to a physical therapist, occupational therapist, massage therapist, or psychologist, as indicated.
Patient teaching
Explain all tests and procedures. Instruct the patient not to wear a lumbosacral support in bed. Describe such pain-relief measures as cold therapy, warm baths, mattress choices, and backboards. Instruct the patient and his family about relaxation techniques, such as deep breathing, biofeedback, and transcutaneous electrical nerve stimulation.
If the patient has chronic back pain, reinforce instructions about bed rest, analgesics, anti-inflammatory medications, and exercise. (See Exercises for chronic low back pain, page 41.) Help him recognize the need to make lifestyle changes, such as losing weight or correcting poor posture. Advise the patient with acute back pain secondary to a musculoskeletal problem to continue his daily activities as tolerated rather than staying on total bed rest.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Lower back pain
» Next page: Back pain (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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