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Rest. Two to three days of bed rest in a supine position may be recommended for patients with acute radiculopathy. Sitting raises intradiscal pressures and can theoretically worsen disc herniation and pain. Activity modification is recommended for patients with nonneurogenic pain. With activity restriction, the patient avoids painful arcs of motion and tasks that exacerbate the back pain.

Physical therapy modalities

Superficial heat, ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the onset of low back pain. These modalities provide analgesia and muscle relaxation. However, their use should be limited to the first two to four weeks after the injury.

No convincing evidence has demonstrated the long-term effectiveness of lumbar traction and transcutaneous electrical stimulation in relieving symptoms or improving functional outcome.

Corsets (lumbosacral orthoses, braces, back supports and abdominal binders) for a short period (a few weeks) may be indicated in patients with osteoporotic compression fractures.

Aerobic exercise has been reported to improve or prevent back pain. Exercise programs that facilitate weight loss, trunk strengthening and the stretching of musculotendinous structures appear to be most helpful in alleviating low back pain. Exercises should promote the strengthening of muscles that support the spine.

Trigger point injections can provide extended relief for localized pain sources. An injection of 1 to 2 mL of 1 percent lidocaine (Xylocaine) without epinephrine is usually administered. Epidural steroid injection therapy has been reported to be effective in patients with lumbar disc herniation with radiculopathy.

Indications for herniated disc surgery. While most patients with a herniated disc may be effectively treated conservatively. Indications for referral include the following: (1) cauda equina syndrome, (2) progressive neurologic deficit, (3) profound neurologic deficit and (4) severe and disabling pain refractory to four to six weeks of conservative treatment.

The mainstay of pharmacologic therapy for acute low back pain is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If no medical contraindications are present, a two- to four-week course of medication at anti-inflammatory levels is suggested.

Naproxen ( Naprosyn) 500 mg followed by 250 mg PO tid-qid prn [250, 375,500 mg].

Naproxen sodium ( Aleve) 200 mg PO tid prn.

Napro xen sodium (Ana prox) 550 mg, followed by 275 mg PO tid-qid prn.

Ibupro fen (Motr in, Advil) 800 mg, then 400 mg PO q4-6h prn.

Diclofenac ( Voltaren) 50 mg bid-tid or 75 mg bid.

Adequate gastrointestinal prophylaxis, using a histamine H2 antagonist or misoprostol (Cytotec), should be prescribed for patients who are at risk for peptic ulcer disease.

Rofecoxib (Vioxx) and celecoxib (Celebrex) are NSAIDs with selective cyclo-oxygenase-2 inhibition. These agents have fewer gastrointestinal side effects.

Celecoxib ( Celebrex) is given as 200 mg qd or 100 mg bid.

Rofecoxib ( Vioxx) is given as 25-50 mg qd.

For relief of acute pain, short-term use of a narcotic may be considered.

Laboratory tests

Evaluation may include a complete blood count, determination of erythrocyte sedimentation rate.

Radiographic evaluation. Plain-film radiography is rarely useful in the initial evaluation of patients with acute-onset low back pain. Plain-film radiographs are normal or demonstrate changes of equivocal clinical significance in more than 75 percent of patients with low back pain. Views of the spine uncover useful information in fewer than 3 percent of patients. Anteroposterior and lateral radiographs should be considered in patients who have a history of trauma, neurologic deficits, or systemic symptoms.

Magnetic resonance imaging and computed tomographic scanning

Magnetic resonance imaging (MRI) and computed tomographic (CT) scanning often demonstrate abnormalities in “normal” asymptomatic people. Thus, positive findings in patients with back pain are frequently of questionable clinical significance.

MRI uses no ionizing radiation and is better at imaging soft tissue (eg, herniated discs, tumors). CT scanning provides better imaging of cortical bone (eg, osteoarthritis). MRI has the ability to demonstrate disc damage, including anular tears and edema. MRI can reveal bulging and degenerative discs in asymptomatic persons. MRI or CT studies should be considered in patients with worsening neurologic deficits or a suspected systemic cause of back pain such as infection or neoplasm. These imaging studies may also be appropriate when referral for surgery is a possibility.

Bone scintigraphy or bone scanning, can be useful when radiographs of the spine are normal but the clinical findings are suspicious for osteomyelitis, bony neoplasm or occult fracture.

Physiologic assessment. Electrodiagnostic assessments such as needle electromyography and nerve conduction studies are useful in differentiating peripheral neuropathy from radiculopathy or myopathy. Electrodiagnostic studies may not add much if the clinical findings are not suggestive of radiculopathy or peripheral neuropathy.

History of significant trauma Neurologic deficits Systemic symptoms Temperature greater than 38EC (100.4EF) Unexplained weight loss Medical history

Cancer Corticosteroid use Drug or alcohol abuse

Ankylosing spondylitis suspected

Waddell Signs: Nonorganic Signs Indicating the Presence of a Functional Component of Back Pain

Superficial, nonanatomic tenderness Pain with simulated testing (eg, axial loading or pelvic rotation) Inconsistent responses with distraction (eg, straight leg raises while the patient is sitting)

Nonorganic regional disturbances (eg, nondermatomal sensory loss) Overreaction

Location of Pain and Motor Deficits in Association with Nerve Root Involvement

Cauda equina syndrome. Only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions. A central herniated disc may also compress nerve roots of the cauda equina, resulting in difficult urination, incontinence or impotence. If bowel or bladder dysfunction is present, immediate referral to a specialist is required for emergency surgery to prevent permanent loss of function.

Physical and neurologic examination of the lumbar spine

External manifestations of pain, including an abnormal stance, should be noted. The patient’s posture and gait should be examined for sciatic list, which is indicative of disc herniation. The spinous processes and interspinous ligaments should be palpated for tenderness.

Range of motion should be evaluated. Pain during lumbar flexion suggests discogenic pain, while pain on lumbar extension suggests facet disease. Ligamentous or muscular strain can cause pain when the patient bends contralaterally.

Motor, sensory and reflex function should be assessed to determine the affected nerve root level. Muscle strength is graded from zero (no evidence of contractility) to 5 (complete range of motion against gravity, with full resistance).
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Specific movements and positions that reproduce the symptoms should be documented. The upper lumbar region (L1, L2 and L3) controls the iliopsoas muscles, which can be evaluated by testing resistance to hip flexion. While seated, the patient should attempt to raise each thigh while the physician’s hands are placed on the leg to create resistance. Pain and weakness are indicative of upper lumbar nerve root involvement. The L2, L3 and L4 nerve roots control the quadriceps muscle, which can be evaluated by manually trying to flex the actively extended knee. The L4 nerve root also controls the tibialis anterior muscle, which can be tested by heel walking.

The L5 nerve root controls the extensor hallucis longus, which can be tested with the patient seated and moving both great toes in a dorsiflexed position against resistance. The L5 nerve root also innervates the hip abductors, which are evaluated by the Trendelenburg test. This test requires the patient to stand on one leg; the physician stands behind the patient and puts his or her hands on the patient’s hips. A positive test is characterized by any drop in the pelvis on the opposite side and suggests either L5 nerve root pathology.

Cauda equina syndrome can be identified by unexpected laxity of the anal sphincter, perianal or perineal sensory loss, or major motor loss in the lower extremities.

Nerve root tension signs are evaluated with the straight_leg raising test in the supine position. The physician raises the patient’s legs to 90 degrees. Normally, this position results in only minor tightness in the hamstrings. If nerve root compression is present, this test causes severe pain in the back of the affected leg and can reveal a disorder of the L5 or S1 nerve root.

The most common sites for a herniated lumbar disc are L4_5 and L5_S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee.

A crossed straight leg raising test may suggest nerve root compression. In this test, straight_leg raising of the contralateral limb reproduces more specific but less intense pain on the affected side. In addition, the femoral stretch test can be used to evaluate the reproducibility of pain. The patient lies in either the prone or the lateral decubitus position, and the thigh is extended at the hip, and the knee is flexed. Reproduction of pain suggests upper nerve root (L2, L3 and L4) disorders.

Approximately 90 percent of adults experience back pain at some time in life, and 50 percent of persons in the working population have back pain every year.

Evaluation of low back pain

A comprehensive history and physical examination can identify the small percentage of patients with serious conditions such as infection, malignancy, rheumatologic diseases and neurologic disorders. The possibility of referred pain from other organ systems should also be considered.

The history and review of systems include patient age, constitutional symptoms and the presence of night pain, bone pain or morning stiffness. The patient should be asked about the occurrence of visceral pain, claudication, numbness, weakness, radiating pain, and bowel and bladder dysfunction.

Specific characteristics and severity of the pain, a history of trauma, previous therapy and its efficacy, and the functional impact of the pain on the patient’s work and activities of daily living should be assessed.
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History and Physical Examination in the Patient with Acute Low Back Pain

History Onset of pain (eg, time of day, activity) Location of pain (eg, specific site, radiation of pain) Type and character of pain (sharp, dull) Aggravating and relieving factors Medical history, including previous injuries Psychosocial stressors at home or work “Red flags”: age greater than 50 years, fever, weight loss

Physical examination Informal observation (eg, patient’s posture, expressions, pain behavior) Comprehensive general physical examination, with attention to specific areas as indicated by the history

Neurologic evaluation Back examination

Palpation

Range of motion or painful arc Stance Gait Mobility (test by having the patient sit, lie down and stand up) Straight leg raise test
Differential Diagnosis of Acute Low Back Pain
The most common levels for a herniated disc are L4_5 and L5_S1. The onset of symptoms is characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee. Pain is generally superficial and localized, and is often associated with numbness or tingling. In more advanced cases, motor deficit, diminished reflexes or weakness may occur.

If a disc herniation is responsible for the back pain, the patient can usually recall the time of onset and contributing factors, whereas if the pain is of a gradual onset, other degenerative diseases are more probable than disc herniation.

Rheumatoid arthritis often begins in the appendicular skeleton before progressing to the spine. Inflammatory arthritides, such as ankylosing spondylitis, cause generalized pain and stiffness that are worse in the morning and relieved somewhat throughout the day.