Red flags for serious back pain Fever, weight loss Pain with recumbency, nocturnal pain Morning stiffness Persistent pain lasting > 6 weeks Age over 50 with new onset pain Abnormal neurology Point tenderness

Further evaluation Goal is to discriminate between “ benign” cases and disorders that require further diagnostic studies Radiological imaging: Xray/ CT Scan/ MRI Useful lab tests: FBC, ESR Calcium, ALP protein electrophoresis

What should I be worried about? Herniated disc Spinal stenosis Cauda equina syndrome Inflammatory spondylarthropathy Spinal infection Vertebral fracture Cancer Referred visceral pain

Imaging Studies: Spinal Stenosis CT scan shows spinal stenosis due to hypertrophic changes in the facet joints CT myelogram reveals canal occlusion with flexion due to spondylolisthesis

Disk Herniation MRI image shows a protruding disk (arrow) that compresses the thecal sac (short arrow)

Ankylosing Spondylitis: X-Ray Changes

Spinal infection — X-Rays

Multiple compression fractures Osteoporosis- X-Ray Multiple compression fractures

Multiple Myeloma RRed flags for spinal malignancy PPain worse at night OOften associated local tenderness CFBC, ESR, protein electrophoresis if ESR elevated

When is surgical referral indicated? Sciatica and probable herniated discs Cauda equina syndrome Progressive or severe neurological deficit Persistent neuromotor deficit after 4-6 weeks conservative treatment Persistent sciatica with consistent neurologic and clinical findings

When is surgical referral indicated? Spinal Stenosis Progressive or severe neurological deficit Persistent back and leg pain improving with flexion and associated with spinal stenosis on imaging Spondylolisthesis Severe back pain/ sciatica with functional impairment that persists > 1 year

Key Points about low back pain 90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mths Pursue diagnostic workup if any red flags found during initial evaluation If ESR elevated, evaluate for malignancy or infection In older patients initial Xray useful to diagnose compression fracture or tumuor

Key Points about low back pain Bed rest is not recommended for low back pain or sciatica, with a rapid return to normal activities usually the best course Back exercises are not useful for the acute phase but help to prevent recurrences and treat chronic pain Surgery is appropriate for a small portion of patients with low back pain

Further reading Deyo RA, Weinstein JN. Low back pain. NEJM 2001;344:363-370 Malmivaara A, Hakkinen U, et al. The treatment of acute low back pain. NEJM 1995;332:351-355 Borenstein DG. Low back pain. In:Klippel J , Dieppe P, editors. Rheumatology. London : Mosby; 1994. p.5.4.1-5.4.26