2. 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

3. 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

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

5. 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

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

7. Ankylosing Spondylitis: X-Ray Changes

8. Spinal infection — X-Rays

9. Multiple compression fractures
Osteoporosis- X-Ray
Multiple compression fractures

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

11. 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

12. 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

13. 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

14. 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

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