Acute_LBP

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Acute Low Back Pain

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Acute Low Back Pain SummaryDefinition

Low back pain (LBP) is posterior trunkpain between the ribcage and the gluteal

folds. It also includes lower extremity painthat results from low back disorder(sciatica/radiating low back pain),

whether there is trunk pain or not.

Acute LBP: Back pain

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Acute Low Back Pain SummaryEpidemiology

The one year point prevalence of low backproblems in the U.S. population is 15-20%.

Eighty percent of the population will experience

at least one episode of disabling low back painduring their lifetime.

Within 6 weeks 90% of episodes will resolvesatisfactorily regardless of treatment [evidenceC*]. 50% of episodes of low back pain withradiating symptoms will resolve spontaneously in6 weeks.

No anatomical diagnosis is provable in 85% ofepisodes [evidence D*].

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Low Back Pain SummaryHistory and physical

Three big questions

Is there underlying systemic ds?

Is there neurologic impairment?

Is social or psychological distressamplifying or prolonging the pain?

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Low Back Pain SummaryHistory and physical

Differential Diagnosis, incidence

Mechanical low back or leg pain 97%

Nonmechanical spinal conditions 1%

Neoplasm, infection, inflammatory arthritis,etc.

Visceral diseases 2% Pelvic, renal, GI, aortic

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Acute Low Back Pain SummaryRed Flags

Red Flags" for Serious Disease

Progressive neurologic deficit

Recent bowel or bladder dysfunction

Saddle anesthesia Traumatic onset

Age > 50

Male with diffuse osteoporosis or compression fracture

Cancer history

Insidious onset No relief at bedtime or worsens when supine

Constitutional symptoms (e.g. fever, weight loss)

Hx UTI/other infection, IV drug use, TB exposure

Immune suppression, Steroid use history

Previous surgery

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Acute Low Back Pain SummaryHistory and Physical

History should include questions tohelp rule out Nonmechainical and

Visceral causes of pain Remember Red Flags

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Low Back Pain Summary

History and Physical

Age > 50yrs or cancer history or

unexplained weight loss or failure of

conservative management.100% sensitive in screening for malignancy

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Low Back Pain Summary

Waddells Signs

1. Overreaction during the exam

2. Simulated testing. Positive when pain is reported with axialloading (pressing on top of the head) or rotation with the pelvisand shoulders in the same plane.

3. Distracted testing. Test straight leg raise while distracted whensitting. (e.g. extend knee in sitting position while appearing tobe performing a Babinski reflex)

4. Superficial, nonanatomical or variable tenderness. When skinrolling over the back markedly increases the pain. Mark areas of

tenderness and examine later for reproducibility. 5. Nonanatomical motor or sensory disturbances. Positive when

sensory loss does not follow a dermatome or entire leg is numbor without strength or when there is a ratchety giveway onstrength testing.

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Acute Low Back Pain Summary

Diagnostic Studies

RED FLAGS, RED FLAGS, RED FLAGS

Diagnostic studies should only be pursued if

pain is greater than 4-6 weeks or if red flagsare present.

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Diagnostic Studies

Plain X-rays are not specific and not

sensitive for either identifying the cause or

ruling out more serious disease in acutelow back pain without red flags

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Diagnostic Studies

Remember 2/3 of acute disc herniation will

partially or completely resolve in 6 months

as noted on sequential MRIs. Acutesurgery is only necessary in cauda equina

syndrome or progressive neurologic

deficits.

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Diagnostic Studies

Ruling out Cancer

If red flag, age > 50yrs, weight loss, history of

cancer, weight loss, or failure to improve withconservative therapy.

ESR < 20 and normal plain XRs had a 100 %

negative predictive value in a study of 2000

patients

If still very concerned MRI is test of choice

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Diagnostic Studies

Ruling out Ankylosing Spondylitis

Red flags - night pain, pain not responsive to

conservative management or > 6 weeks.Plain XRs, if not diagnostic and still highly

suspicious, MRI is test of choice.

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Diagnostic Studies

Ruling out Fracture

Red flagstrauma, age > 50 yrs

Plain films are sensitive. If continued highsuspicionMRI.

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Treatment

Back exercisesSpecific exercises are notrecommended for acute low back pain(Cochrane)

MassageNo good evidence one way or theother (Cochrane)

AcupunctureMixed evidence, Cochrane does

not recommendBack SchoolProbably of very limited value,

but poor evidence (Cochrane)

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Treatment

Bed Rest Bed rest as compared with

advise to stay active at best will have small

effects and at worst might have smallharmful effects on acute low back pain

(Cochrane)

Netherlands Systematic Reviewrecommend against bed rest.

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Treatment

Lumbar supports - Not recommended for

treatment of acute low back pain

(Cochrane)Heat therapyLimited evidence supports

the use of heat for the treatment of acute

low back pain

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Treatment

TENSConflicting results of two RTCs

(Netherlands Systematic Review)

ManipulationLimited evidence thatmanipulation is more effective than

placebo (Netherlands Systematic Review)

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Treatment

NSAIDsThere is conflicting evidence thatNSAIDs provide better pain relief than placebo inacute low back pain (Cochrane)

NSAIDs vs Acetaminophenmixed results,probably equal

NSAIDs vs Opioidsequally effective

(Cochrane)NSAIDs vs Muscle relaxantsequally effective

(Cochrane)

All NSAIDS are equal (Cochrane)

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Treatment

Acetaminophenno trials compared to

placebo. RCTs probably equal to NSAIDs

and opioids.Muscle relaxants vs placebomuscle

relaxants superior to placebo ( Clinical

Evidence). High quality studies comparingdifferent muscle relaxants found no

difference in efficacy.

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Treatment

Opioidsas efficacious as NSAIDs and

acetaminophen in relief of low back pain but not

better.ColchicineSmall RCT compared to placebo, no

significant differences.

Antidepressantscurrently poorly studied but

ongoing studies for treatment of acute low back

pain. Role very unclear at this point.

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Documents

Acute_LBP