Diagnosis	Treatment
Diagnosis	Recommended	Not Recommended
D1: Undertake diagnostic triage (serious spinal pathology, nerve root pain/radicular pain, or nonspecific low back pain), consisting of appropriate history and physical examination, at the first assessment.	T1: Give adequate information and reassure the patient.	T2: Prescription of bed rest as a treatment.
D2: Assess for psychosocial risk factors (yellow flags; see Table 1.3) and review them in detail if there is no improvement.	T3: Advise the patient to stay active and to continue normal daily activities, including work if possible.	T4: Specific exercises for acute low back pain.
D3: Diagnostic imaging tests (including radiographs, CT, and MRI) are not routinely indicated for acute low back pain.	T5: Prescribe medication, if necessary, for pain relief.	T6: Epidural corticosteroid injections for acute nonspecific low back pain.
D4: Reassess the patient whose symptoms fail to resolve.	T7: Consider spinal manipulation for patients who are failing to return to normal activities.T13: Consider multidisciplinary treatment programs in occupational settings for workers on sick leave for more than 4-8 weeks.	T8: “Back schools” for treatment of acute low back pain.T9: Behavioral therapy for treatment of acute low back pain.T10: Traction.T11: Massage as a treatment for acute nonspecific low back pain.T12: Transcutaneous electrical nerve stimulation (TENS) as a treatment for acute nonspecific low back pain.

Diagnostic triage of acute LBP consists of the following conditions (see Box 1.1):

▪ Serious spinal pathology

▪ Nerve root pain/radicular pain

▪ Nonspecific LBP

Red flags in the diagnosis of LBP are signs that a serious spinal pathology may be the cause of the LBP; they are listed in Table 1.3:

Table 1.3 Red and Yellow Flags in Diagnosis of Low Back Pain

Red flags (signs of serious pathology)

Patient’s age at onset < 20 years or > 55 years

Recent history of violent trauma

Constant progressive, nonmechanical pain (no relief with bed rest)

Thoracic pain

Past medical history of malignant tumor

Prolonged use of corticosteroids

Drug abuse, immunosuppression, human immunodeficiency virus

Systemic “unwellness”

Unexplained weight loss

Widespread neurologic symptoms (including cauda equina syndrome)

Structural deformity

Fever

Yellow flags (psychosocial risk factors)

Inappropriate attitudes and benefits about back pain (e.g., belief that back pain is potentially harmful or severely disabling, high expectations of passive treatments rather than belief that active participation will help)

Inappropriate pain behavior (e.g., fear-avoidance behavior and reduced activity levels)

Emotional problems (e.g., depression, anxiety, stress, tendency to low mood, withdrawal from social interaction)

Signs or symptoms of neurologic involvement in a patient with LBP are complaint of numbness or weakness in the legs and sciatica with radiation past the knee. The following features apply to possible diagnosis of sciatica:

▪ When pain radiates only to the posterior thigh, it is less likely that the pain is caused by a true radiculopathy.

▪ Sciatica has such a high sensitivity (95%) that its absence makes lumbar disc herniation unlikely.

▪ The likelihood of disc herniation in a patient without sciatica would be 1 in 1000.

Because more than 95% of lumbar disc herniations occur at the L4-L5 or L5-S1 level, the neurologic examination should focus on the L5 and S1 nerve roots; however, upper lumbar nerve root involvement may be suggested when pain conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes.

Psychosocial yellow flags are patient factors that increase the risk for development or perpetuation of chronic pain and long-term disability (including work loss associated with LBP); examples are listed in Table 1.3. Identification of yellow flags should lead to appropriate cognitive and behavioral management.

Considerations for diagnosis

Cauda equina syndrome is a condition requiring emergency evaluation and surgery. A patient with LBP should be referred immediately to the emergency room if any of the following emergency symptoms is present:

▪ Sudden onset of or otherwise unexplained loss of or changes in bowel or bladder control (retention or incontinence)

▪ Sudden onset of or otherwise unexplained bilateral leg weakness

▪ Saddle numbness

A patient should be examined within 24 hours if the patient requests a same-day appointment or any of the following urgent symptoms is present:

▪ Fever (38° C or 100.4° F) for more than 48 hours

▪ Unrelenting night pain or pain at rest

▪ Pain with distal (below the knee) numbness or weakness of leg(s)

▪ Progressive neurologic deficit

Is evaluation indicated? A patient should be offered an appointment within 2 to 7 days if any of the following symptoms or patient factors is present:

▪ Exertion injury (e.g., lifting, digging, reaching)

▪ History of back symptoms—patient has been seen before, at least once

▪ Chronic back pain lasting longer than 6 weeks

▪ Unexplained weight loss (more than 10 pounds in 6 months)

▪ Age more than 50 years

▪ History of cancer

Performance of lumbar spine radiographs should be limited to presence of any of the following red flag indications:

▪ Unrelenting night pain or pain at rest

▪ Fever above 38° C or 100.4° F for more than 48 hours

▪ Progressive neuromotor deficit

▪ Pain with distal numbness or leg weakness

▪ Loss of bowel or bladder control (retention or incontinence)

▪ Clinical suspicion of ankylosing spondylitis

▪ Significant trauma

▪ History or suspicion of cancer

▪ Osteoporosis

▪ Long-term oral steroid therapy

▪ Immunosuppression or immunosuppressive therapy

▪ Drug or alcohol abuse

Advanced imaging studies should be performed only for the patient with the following findings:

▪ Progressive neurologic deficit

▪ Minimal to no improvement of radicular symptoms despite 6 weeks of conservative treatment

▪ Uncontrolled pain

▪ Cauda equina syndrome

Epidemiology of low back pain

The lifetime prevalence of LBP is reported as more than 70% in industrialized countries (1-year prevalence, 15% to 45%; adult incidence, 5% per year). Peak prevalence occurs between ages 35 and 55.

Symptoms, pathology, and radiologic appearances in patients with LBP are poorly correlated. Pain is not attributable to pathology or neurologic encroachment in about 85% of people. About 4% of people seen with LBP in primary care have compression fractures, and about 1% have a neoplasm. Ankylosing spondylitis and spinal infections are even more rare. The prevalence of prolapsed intervertebral disc is about 1% to 3%.

Risk factors for LBP are poorly understood. The most frequently reported are as follows:

1. Heavy physical work.

2. Frequent bending, twisting, lifting, pulling and pushing.

3. Repetitive work.

4. Static postures.

5. Vibrations.

6. Psychosocial risk factors, including stress, distress, anxiety, depression, cognitive dysfunction, pain behavior, job dissatisfaction, and mental stress at work.

Outcomes

The aims of treatment for acute LBP are as follows:

▪ To relieve pain

▪ To improve functional ability

▪ To prevent recurrence and chronicity

Relevant outcomes for acute LBP are as follows:

▪ Overall improvement in pain intensity

▪ Improvement in back pain–specific functional status

▪ Positive impact on employment

▪ Improvement in generic functional status

▪ Decrease in medication use

Intervention-specific outcomes may also be relevant; examples are as follows:

▪ Behavioral treatment may improve coping and pain behavior.

▪ Exercise therapy may improve strength and flexibility.

▪ Antidepressants may decrease the symptoms of depression.

▪ Muscle relaxants may reduce the symptoms of muscle spasm.

Treatment of Acute Low Back Pain in Primary Care

The aims of treatment for acute LBP in primary care are to:

▪ Provide adequate information, reassuring the patient that LBP is usually not a serious disease and that rapid recovery is expected in most cases.

▪ Provide adequate symptom control, if necessary.

▪ Encourage the patient to stay as active as possible and to return to normal activities, including work, as early as possible.

▪ Emphasize patient education and conservative home self-care.

An active approach is the best treatment option for acute LBP. Passive treatment modalities (for example, bed rest, massage, ultrasound, electrotherapy, laser, and traction) should be avoided as monotherapy and should not be routinely be used, because they may increase the risk of illness behavior and chronicity.

Patient education and conservative home self-care consist of the following activities and medications:

▪ Anti-inflammatory and analgesic over-the-counter medications

▪ Early return to work or activities

Patients with acute LBP should be advised to stay active and continue ordinary and daily activity within the limits permitted by the pain. For chronic back pain, there is evidence that exercise therapy is effective.

Natural History of Low Back Pain

Acute LBP is usually self-limiting (the recovery rate is 90% within 6 weeks), but chronic pain develops in 2% to 7% of people. Recurrent LBP and chronic LBP account for 75% to 85% of total worker absenteeism. Most patients will experience partial improvement in 4 to 6 weeks and have a recurrence of LBP in 12 months.

A General Assessment of Patients Reporting Low Back Pain

The patient presenting for low back pain should undergo assessment that establishes answers to the following questions:

▪ Has the patient had any recent back procedure or epidural anesthesia?

▪ What is the location of pain—simple LBP (does not radiate past the knee) versus sciatica (LBP with radiation past the knee)?

▪ What is the duration of symptoms, including date of injury or onset of symptoms? LBP for 6 weeks or less is acute; LBP for more than 6 weeks is chronic.

▪ If the pain is a result of an injury, how did the injury occur?

▪ Is the patient experiencing unrelenting or severe pain—rated on a scale of 0 to 10, with 10 indicating most severe pain?

▪ Are other medical conditions present?

▪ Does the patient have a history of previous back pain or surgery?

▪ Are any psychosocial factors present?

Psychosocial Factors to consider include the following:

▪ Belief that pain and activity are harmful

▪ “Sickness behavior” such as extended rest

▪ Depressed or negative moods, social withdrawal

▪ Self-treatment that does not fit best practice

▪ Problems with disability claim and compensation

▪ History of back pain, time off, or other claim

▪ Problems at work or low job satisfaction

▪ Heavy work, unsociable hours

▪ Overprotective family or lack of support

▪ Other factors, such as fear, financial problems, anger, depression, job dissatisfaction, family problems, and stress, that can contribute to prolonged disability

Relevant Medical History

Key elements of the patient’s medical history when symptoms of spinal pain are present (Boxes 1.2 to 1.4 and Table 1.4) are as follows:

▪ Chief complaint

▪ History of present illness: location, character, severity, duration and timing, context, modifying factors, and associated signs and symptoms

▪ Review of systems

▪ Past history of interventional pain management: history of past pain problems, motor vehicle accidents, and occupational or nonoccupational injuries

▪ Family history: history of pain problems in the family, degenerative disorders, familial disorders, drug dependency, alcoholism, and drug abuse

▪ Psychological disorders: depression, anxiety, schizophrenia, and suicidal tendencies

▪ Social history: environmental information, education, marital status, children, habits, hobbies, and occupational history

BOX 1.2 Waddell Embellishment Tests That Indicate Nonorganic Pathology For Low Back Pain

Modified from Waddell G: 1987 Volvo award in clinical sciences: A new clinical model for the treatment of low-back pain. Spine 1987;12:632-644.

Tests

1. Tenderness: Subcutaneous (or less) pressure reproduces symptoms.

2. Stimulation of symptoms:

a. Loading the spine with the weight of the examiner’s hands on top of the patient’s head (to reproduce back symptoms).

b. Simulation of twisting the trunk when rotating the shoulders and hips in unison to reproduce back pain (can physiologically reproduce sciatica).

3. Distraction: Sitting knee extension to rest sciatic tension while distracting the patient with knee or foot examination as the reason for extending the knee. (If the patient is comfortable during sitting knee extension, the straight-leg raising test result should not be positive; a positive result of that test is of questionable significance.)

4. Nonanatomic distribution of pain: As seen on a pain drawing (total body or outside the body) or demonstrated on muscle testing (intermittent efforts).

5. Overreaction: Grimacing, complaints, or suffering displays are inappropriate for the situation or maneuver.

Scoring

A score of 0 to 2 (up to two positive responses) is normal. Three to five positive responses (score of 3 to 5) warn the clinician that nonphysical interference may render the history and physical findings somewhat confusing (identifying a need for a greater focus on objective measures). The more positive Waddell test responses, the greater the chance that nonphysical factors may alter the patient’s response to the physician’s care and potentially lower the clinical expectations for an excellent outcome from both surgical and nonsurgical treatments.

BOX 1.3 Referral Guidelines For Presurgical Psychological Screening

Guidelines for Referral

Presence of no or 1 item: Referral not needed unless desired by patient.

Presence of 2-4 items: Referral should be considered.

Presence of 4 or more items: Referral should be strongly considered.

BOX 1.4 Preoperative Psychological Screening Risk Factors For Poor Surgical Outcome

MMPI, Minnesota Multiphasic Personality Inventory.

Preoperative Psychological Screening Prognosis

Good: 0-4 risk factors

Fair: 5-8 risk factors

Poor: 9-14 risk factors

Table 1.4 History Taking for Spinal Pain

Question/Subject	Answer	Diagnostic Significance
Age	Young	Disc injuries, spondylolisthesis
	Middle age	Sprain/strain, herniated disc, degenerative disc disease
	Elderly	Spinal stenosis, herniated disc, degenerative disc disease, arthritis
Pain:
Character	Radiating (shooting)	Radiculopathy (herniated disc, spondylosis)
Character	Diffuse, dull, nonradiating	Cervical or lumbar strain (soft tissue injury)
Location	Unilateral vs. bilateral	Unilateral: herniated disc Bilateral: systemic or metabolic disease, space-occupying lesion

Neck Cervical spondylosis, neck sprain, muscle strain Arm (± radiation) Cervical spondylosis (± myelopathy), neck sprain, muscle strain Lower back Degenerative disc disease, back sprain, muscle strain Legs (± radiation) Herniated disc, spinal stenosis Occurrence Night pain Tumor With activity Usually mechanical etiology Alleviated by Arm elevation Herniated cervical disc Sitting down Spinal stenosis (stenosis relieved) Exacerbated by Back extension Spinal stenosis (e.g., going down stairs) Trauma Motor vehicle accident (seatbelt?) Cervical strain (whiplash), cervical fractures, ligamentous injury Activity Sports (stretching injury) “Burners/stingers” (especially in football) Neurologic symptoms Pain, numbness, tingling Radiculopathy, neuropathy Spasticity, clumsiness Myelopathy Bowel or bladder symptoms Cauda equina syndrome Systemic complaints Fever, weight loss Infection, tumor

Physical Examination

A physical examination for patients with symptoms of spinal pain would include palpation for spinal tenderness, neuromuscular testing, and the straight-leg raise (SLR) test. Table 1.5 summarizes the examination, techniques, and their clinical application in the patient with a complaint of low back pain.

Table 1.5 Physical Examination of the Spine

Neuromuscular testing should be performed to evaluate the following aspects:

▪ Motor: ankle and greater toe dorsiflexion strength

▪ Reflex: ankle and knee reflexes

▪ Sensory: pinprick sensation in the medial, dorsal, and lateral aspect of the foot

Significant or progressive neuromotor deficit requires surgical consultation.

The SLR test should be performed bilaterally to evaluate for nerve root impingement including, but not limited to, disc herniation. A positive SLR test result is defined as the presence of pain in the posterior leg that radiates below the knee when the patient is lying supine and the hip is flexed 60 degrees or less; it is suggestive of disc herniation. A negative SLR test result rules out surgically significant disc herniation in 95% of cases.

Related anatomy and physiology

The spinal muscles on the neck and back are described in Tables 1.6 through 1.9. The spinal nerves are described in Tables 1.10 through 1.15 and shown in Figures 1-1 and 1-2. The spinal blood supply is shown in Figures 1-3 and 1-4 and described in Table 1.16. The intervertebral foraminal ligaments of the lumbar spine are shown in Figure 1-5.

Table 1.6 Anterior Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.7 Posterior Neck Muscles (Suboccipital Triangle): Origins, Insertions, Actions, and Related Innervations

Table 1.8 Superficial (Extrinsic) Posterior Neck and Back Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.9 Deep (Intrinsic) Posterior Neck and Back Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.10 Anterior and Posterior Branches of the Spinal Nerves

Table 1.11 Cervical Plexus (C1-C4 Ventral Rami) behind Internal Jugular Vein and Sternocleidomastoid (SCM) Muscles

Table 1.12 Brachial Plexus

Table 1.13 Lumbar Plexus

Table 1.14 Sacral Plexus and Coccygeal Nerves

Table 1.15 Spinal Nerve Branches and the Territories They Supply

Spinal nerve branch	Motor visceromotor territory	Sensory territory
Ventral ramus	All somatic muscles except for the intrinsic back muscles	Skin of the lateral and naterior trunk wall and of the upper and lower limbs
Dorsal ramus	Intrinsic back muscles	Posterior skin of the head and neck, skin of the back and buttock
Menigeal ramus	–	Spinal meniges, ligaments of the spinal column, capsules of the facet joints
White ramus communicans	Carries preganglionic fibers from the spinal nerve to the sympathetic trunk (‘White’ because the preganglionic fibers are myelinated)	–
Gray ramus communicans*	Carrries postganglionic fibers from the sympahetic trunk back to the spinal nerve (‘Gray’ because the fibers are unmyelinated)	–

* Strictly speaking, the gray ramus communicans is not a spinal nerve branch but a branch passing from the sympathetic trunk to the spinal nerve.

Figure 1–1 Anterior view of the nerves of the trunk wall.

Figure 1–2 Branches of the spinal nerves. Formed by the union of the dorsal (sensory) and ventral (motor) roots, the approximately 1 cm–long spinal nerve courses through the intervertebral foramen and divides into five branches after exiting the vertebral canal (see Table 1.15).

Figure 1–3 Composite schema of blood supply to the spinal cord and nerve roots showing two regions of the cord. Note the distribution between medullary arteries and true radicular arteries and that the medullary arteries usually run a course that is independent of the roots. 1, Dorsolateral longitudinal artery; 2, proximal radicular artery (of dorsal root); 3, dorsal medullary artery; 4, dorsal root of the thoracic spinal nerve; 5, distal radicular artery (of dorsal root); 6, sinuvertebral nerve; 7, dorsal ramus of spinal nerve; 8, segmental artery; 9, dorsal central artery; 10, dorsal root ganglion; 11, anterior laminar artery; 12, ventral ramus of spinal nerve; 13, rami communicantes; 14, ventral root of spinal nerve; 15, proximal radicular artery of ventral root; 16, periradicular theca of dura; 17, dorsal meningeal branch of vertebromedullary artery; 18, dura; 19, ventral meningeal plexus; 20, great ventral medullar artery (great “radicular” artery of Adamkiewicz); 21, anterior (ventral) spinal artery; 22, vasa corona of spinal cord; 23, spinal nerve; 24, ventral medullary artery of thoracic cord.

Figure 1–4 Schema showing the venous relations of a lumbar vertebra. The divisions of the network are the internal vertebral plexus, which surrounds the dura and is drained by veins in the intervertebral foramina; the basivertebral veins on the back of the vertebral bodies, which drain a network in the marrow spaces of the vertebrae; and the external vertebral plexus, which lies on the anterior and lateral sides of the vertebral bodies and on the vertebral arches. 1, Dorsal external vertebral plexus; 2, dorsal epidural plexus; 3, ascending lumbar veins; 4, basivertebral vein; 5, anterior ventral external vertebral plexus; 6, lumbar segmental vein; 7, muscular vein from posterior abdominal wall; 8, circumferential channels (sinuses) of epidural plexus; 9, ventral epidural plexus; 10, internal ventral and dorsal venous plexus; 11, lateral ventral external vertebral plexus.

Table 1.16 Spinal Arteris^*

Figure 1–5 Intervertebral foraminal ligaments of the lumbar spine: A, corporo-transverse superior and corporo-transverse inferior; B, superior transforaminal ligament ; C, mid- transforaminal ligament; D, inferior transforaminal ligament; E, posterior transforaminal ligament. Enlarged image shows all ligaments in context.

(Modified from Park HK, Rudrappa S, Dujovny M, Diaz FG: Intervertebral foraminal ligaments of the lumbar spine: Anatomy and biomechanics. Childs Nerv Syst 2001;17:275-282.)