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Chapter 54. Low Back Pain
Chapter 54. Low Back Pain
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The Patient History: An EvidenceBased Approach to Differential Diagnosis, 2e
Chapter 54. Low Back Pain
M.E. Beth Smith, DO; Roger Chou, MD; Richard A. Deyo, MD, MPH
Case Scenario
A 51yearold woman presents to your clinic with a complaint of low back pain, which began acutely 2 weeks earlier, 1 day after a 10km run. The pain is
described as achy, intermittent, and located in the central region of her low back. It is associated with an occasional electrical sensation shooting down
her left leg. The pain is aggravated by rolling over in bed, prolonged sitting, and running; it is relieved by rest, changing positions, and ibuprofen.
What additional questions would you ask to learn more about her low back pain?
How do you classify low back pain?
How do you determine whether her symptoms are worrisome for a serious neurologic, systemic, or nonspinal condition?
What features suggest a better or worse prognosis for developing a chronic disabling condition?
How do you determine whether further diagnostic or therapeutic intervention in indicated?
Introduction
Low back pain (LBP) is a common reason for office appointments in the United States, accounting for 2% of all visits.1 Approximately 70% of adults will
have an episode of LBP during their lifetime, and 25% to 40% will have multiple episodes.1,2 It is also one of the most costly conditions in terms of time
lost from work and decreased productivity while at work.2,3 Additionally, the prevalence of chronic LBP seems to be increasing. In North Carolina, the
prevalence of persistent back pain that interfered with function increased from 3.9% in 1992 to 10.2% in 2006.3 A small minority of patients with
chronic disabling LBP account for a disproportionate share of the healthcare costs. Fortunately, most cases of acute LBP follow a benign, selflimited
course with substantial improvement or resolution within the first 4 to 8 weeks.4 The practitioner must identify worrisome features suggesting a
serious etiology or risk of developing a chronic disabling condition.
Key Terms
Acute LBP An episode of back pain lasting < 3 months in duration, most commonly < 2 weeks.
Ankylosing Inflammatory disorder affecting primarily the axial skeleton with symptoms usually beginning in late adolescence or early
spondylitis adulthood, the hallmark being sacroiliitis.
Cauda equina Acute compressive radiculopathy of the sacral nerve roots that comprise the cauda equina. Symptoms include severe back
syndrome pain, urinary retention or urinary and fecal incontinence, saddle anesthesia, and leg weakness. Arises most commonly from a
large midline disk herniation but can complicate any process that leads to spinal canal narrowing at the level of the cauda
equina (eg, tumor, spinal stenosis).
Chronic LBP An episode of back pain lasting > 3 months in duration.
Myelopathy Pathologic disturbance of spinal cord function manifested by peripheral muscle weakness, increased muscle tone, spasticity,
and hyperreflexia.
Radiculopathy A nonspecific term referring to the compression or irritation of a nerve root and manifesting in symptoms of pain, weakness, or
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Neurogenic Pain typically located in the low back, buttocks, and proximal thighs associated with spinal stenosis. Pain is aggravated by
claudication exercise and improves with rest, sitting, or leaning forward.
course with substantial improvement or resolution within the first 4 to 8 weeks.4 The practitioner must identify worrisome features suggesting a
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serious etiology or risk of developing a chronic disabling condition.
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Key Terms
Acute LBP An episode of back pain lasting < 3 months in duration, most commonly < 2 weeks.
Ankylosing Inflammatory disorder affecting primarily the axial skeleton with symptoms usually beginning in late adolescence or early
spondylitis adulthood, the hallmark being sacroiliitis.
Cauda equina Acute compressive radiculopathy of the sacral nerve roots that comprise the cauda equina. Symptoms include severe back
syndrome pain, urinary retention or urinary and fecal incontinence, saddle anesthesia, and leg weakness. Arises most commonly from a
large midline disk herniation but can complicate any process that leads to spinal canal narrowing at the level of the cauda
equina (eg, tumor, spinal stenosis).
Chronic LBP An episode of back pain lasting > 3 months in duration.
Myelopathy Pathologic disturbance of spinal cord function manifested by peripheral muscle weakness, increased muscle tone, spasticity,
and hyperreflexia.
Radiculopathy A nonspecific term referring to the compression or irritation of a nerve root and manifesting in symptoms of pain, weakness, or
sensory loss in the distribution of the nerve.
Neurogenic Pain typically located in the low back, buttocks, and proximal thighs associated with spinal stenosis. Pain is aggravated by
claudication exercise and improves with rest, sitting, or leaning forward.
(pseudoclaudication)
Sciatica Most common symptom of radiculopathy, characterized by pain radiating down the leg in the distribution of the sciatic nerve.
It is most commonly due to compression of the L4, L5, or S1 nerve roots.
Spinal stenosis Narrowing of the spinal canal leading to compression of the spinal cord or cauda equina. It is most commonly seen in older
patients with severe degenerative changes of the spine.
Spondylolisthesis Occurs when one vertebra slips anteriorly over the vertebra below. May be caused by a congenital defect in the pars
interarticularis, although the most common cause in adults is degenerative changes of the facet joints, often associated with
spinal stenosis. Posterior displacement is far less common and is usually called retrolisthesis.
Positive likelihood The increase in odds of a diagnosis if a given clinical factor is present.
ratio (LR+)
Negative likelihood The decrease in odds of a diagnosis if a given clinical factor is absent.
ratio (LR−)
Odds ratio A measure of the odds of an event occurring in one group compared to the odds of the same event occurring in another group.
Etiology
The etiology of most cases of LBP remains elusive. Although specific structures such as muscle, ligaments, or skeletal components may be responsible
for the patient's symptoms, the ability to accurately identify the specific cause remains limited.5–7 Imaging results frequently do not correlate with
examination findings, limiting their utility in terms of reaching a definitive diagnosis. Furthermore, ascribing LBP to a specific etiology often does not
affect treatment decisions or improve patient outcomes.7 It is clinically more useful to classify LBP into 1 of 3 categories:
1. Back pain without radiculopathy
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3. Back pain associated with a systemic disease, organ system, or other specific cause.7
The etiology of most cases of LBP remains elusive. Although specific structures such as muscle, ligaments, or skeletal components may be responsible
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for the patient's symptoms, the ability to accurately identify the specific cause remains limited.5–7 Imaging results frequently do not correlate with
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examination findings, limiting their utility in terms of reaching a definitive diagnosis. Furthermore, ascribing LBP to a specific etiology often does not
affect treatment decisions or improve patient outcomes.7 It is clinically more useful to classify LBP into 1 of 3 categories:
1. Back pain without radiculopathy
2. Back pain associated with radiculopathy
3. Back pain associated with a systemic disease, organ system, or other specific cause.7
Differential Diagnosis
Prevalence1 ,2 ,6 – 8
Degenerative 10%
Spondylolisthesis 3%
Vertebral fracture 1%–4%
Back pain associated with Disk herniation requiring surgical intervention 2%
radiculopathy
Spinal stenosis 3%
Cauda equina 0.0004 (1%–2% of disk
herniations)
Spinal infection 0.01%
Ankylosing spondylitis 0.3%
Osteoporotic compression fracture 4%
Abdominal aortic aneurysm
Renal: pyelonephritis, nephrolithiasis, perinephric abscess
Gastrointestinal: pancreatitis, cholecystitis or cholelithiasis, perforating peptic
ulcer
Urogenital: endometriosis, pelvic inflammatory disease, prostatitis
Getting Started with the History
When evaluating a patient with LBP, the following objectives should guide your approach:
1. Understand the chronology and the nature of the symptoms, including a description of the pain and associated triggers.
2. Determine the functional impact of the condition on the patient.
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3. Identify patients with worrisome or alarming features.
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4. Identify patients at heightened risk of developing a chronic disabling condition.
Getting Started with the History
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When evaluating a patient with LBP, the following objectives should guide your approach: Access Provided by:
1. Understand the chronology and the nature of the symptoms, including a description of the pain and associated triggers.
2. Determine the functional impact of the condition on the patient.
3. Identify patients with worrisome or alarming features.
4. Identify patients at heightened risk of developing a chronic disabling condition.
Start with an openended question and listen to the patient's story. Much can be learned about the impact of the symptoms by active listening and
observation.
Questions Remember
Tell me about your back pain? Listen to the whole story without interruptions.
When did it first start? How has it changed? Reassure the patient when appropriate.
Appreciate the impact that it is having on the patient's life and wellbeing.
Interview Framework
Because 90% of LBP patients seen in a primary care setting will have a mechanical or nonspecific etiology, focus your inquiry on identifying those with a
more serious or specific pathology. If an injury occurred, the mechanics of that injury may be helpful. The following characteristics may help direct
treatment options and identify those at risk of developing a more disabling condition:
Location
Description (allow patients to describe in their own words before offering options)
Duration and frequency (ie, transient versus unremitting, constant versus occasional)
Aggravating and relieving factors
Change in character over time
Identifying Alarm Symptoms
Alarm symptoms are symptoms associated with a greater likelihood of serious underlying disease. Their presence increases the probability of serious
disease, although their absence may not preclude it. Fortunately, serious causes of LBP are uncommon.
Is There Evidence of Neurologic Compromise?
Neurologic compromise in LBP occurs by some form of compression or entrapment either on the spinal canal itself, the cauda equina, or the nerve
root. This is manifested by sensory, motor, or reflex pathway dysfunction, usually causing lower extremity symptoms. Sciatica or leg pain without
weakness or reflex changes is the most common symptom of radiculopathy and generally does not constitute an emergent or urgent concern. Typical
symptoms of sciatica have moderate sensitivity but poor specificity for clinically significant nerve compression including disk herniation (sensitivity
and specificity ranges, 0.74–0.99 and 0.14–0.58, respectfully).9,10 Weakness, however, is considered a more specific symptom of nerve compression
causing neurologic compromise. Whether occurring from disk herniation, spinal stenosis, tumor, or infection, motor weakness must be fully evaluated
to determine the degree of urgency. Patients with isolated sciatica but no motor or reflex changes can be monitored conservatively. Symptoms
persisting with no improvement for more than 1 month may warrant imaging. Plain xray may be appropriate for most, but for surgical candidates,
magnetic resonance imaging is generally preferred over computed tomography.7 Multilevel, profound, or progressive weakness requires urgent
investigation and referral. Myelopathy is typically characterized by leg weakness and spasticity resulting from tumor, infection, or severe degenerative
changes affecting the spinal cord. It often results from cord compression above the lumbar spine because the spinal cord ends at the L1 or L2 level.
Cauda equina syndrome is usually caused by a massive midline disk herniation. Although the prevalence of cauda equina syndrome and myelopathy in
patients with LBP is quite low, both are considered spinal emergencies because delayed treatment may lead to irreversible neurologic damage.
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Presence of Absence of
Quality of
Differential Diagnosis Symptom or Risk Symptom or Risk
the Evidence
persisting with no improvement for more than 1 month may warrant imaging. Plain xray may be appropriate for most, but for surgical candidates,
magnetic resonance imaging is generally preferred over computed tomography.7 Multilevel, profound, or progressive weakness requires urgent
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investigation and referral. Myelopathy is typically characterized by leg weakness and spasticity resulting from tumor, infection, or severe degenerative
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changes affecting the spinal cord. It often results from cord compression above the lumbar spine because the spinal cord ends at the L1 or L2 level.
Cauda equina syndrome is usually caused by a massive midline disk herniation. Although the prevalence of cauda equina syndrome and myelopathy in
patients with LBP is quite low, both are considered spinal emergencies because delayed treatment may lead to irreversible neurologic damage.
Presence of Absence of
Quality of
Differential Diagnosis Symptom or Risk Symptom or Risk
the Evidence
Factor Factor
years)
Typical symptoms of sciatica LR+ 2.2
massive midline disk herniation) as overflow incontinence)
aPain with or without neurologic deficit in the legs most often seen in walking, standing, and/or coughing.
Is There Evidence of a Specific Condition Causing the Symptoms But Without Evidence of
Neurologic Compromise?
When considering whether the patient's symptoms are caused by an underlying disease process or being referred from a visceral structure, consider
the patient's age, comorbid characteristics, and associated symptoms. The most common systemic diseases causing LBP include cancer, osteoporosis
causing compression fracture, infection causing osteomyelitis or abscess, and ankylosing spondylitis. Cancer or infection must be diagnosed and
treated expeditiously because, if untreated, it may result in irreversible neurologic sequelae, pathologic fractures, or progressive disease that is more
difficult to manage. Constant and nocturnal pain not improved with rest is more often associated with a systemic disease process such as cancer.6 The
most significant risk factor for malignancy causing LBP is a personal history of cancer (excluding nonmelanoma skin cancer).7 Any patient with new
back pain and a prior history of cancer should undergo imaging of the spine. Based on the estimated positive likelihood ratio, such a history increases
a patient's probability of cancer from less than 1% in a primary care setting to nearly 9%.7 Other risk factors such as age greater than 50 years,
unexplained weight loss, and failure to improve within 1 month are weaker predictors of cancer, increasing the probability to just over 1%.7 In such
patients, it may be reasonable to forego immediate imaging while treating for nonspecific LBP, unless there are additional features suggestive of
malignancy.
Back pain may also be referred from a visceral structure, often suggested by additional symptoms and underlying medical conditions. For instance,
one must consider abdominal aortic aneurysm in a white male smoker older than age 65 with a history of hypertension. Although evidence on
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historical features of back pain referred from a visceral organ is sparse, isolated LBP seems to be rare. Rather, associated symptoms such as fever,
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nausea, vomiting, and gastrointestinal symptoms are usually present. Visceral pain may have an intermittent colicky nature when referred from an
abdominal or pelvic source.
unexplained weight loss, and failure to improve within 1 month are weaker predictors of cancer, increasing the probability to just over 1%.7 In such
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patients, it may be reasonable to forego immediate imaging while treating for nonspecific LBP, unless there are additional features suggestive of
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malignancy.
Back pain may also be referred from a visceral structure, often suggested by additional symptoms and underlying medical conditions. For instance,
one must consider abdominal aortic aneurysm in a white male smoker older than age 65 with a history of hypertension. Although evidence on
historical features of back pain referred from a visceral organ is sparse, isolated LBP seems to be rare. Rather, associated symptoms such as fever,
nausea, vomiting, and gastrointestinal symptoms are usually present. Visceral pain may have an intermittent colicky nature when referred from an
abdominal or pelvic source.
aFive screening questions: 1. Onset of back discomfort before age 40? 2. Did the problem begin slowly? 3. Persistence for at least 3 months? 4. Morning stiffness? 5. Improved by exercise?
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Differential Diagnosis Features
LR− 0.94
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aFive screening questions: 1. Onset of back discomfort before age 40? 2. Did the problem begin slowly? 3. Persistence for at least 3 months? 4. Morning stiffness? 5. Improved by exercise?
Differential Diagnosis Features
HTN, hypertension; OR, odds ratio.
Focused Questions
QUESTIONS THINK ABOUT…
History
Do you have a personal history of cancer? Malignancy: In patients with a personal history of cancer, new back pain should be considered
malignant until proven otherwise (LR+ 14.7).
Age? > 50: malignancy LR+ 2.7
> 65: abdominal aortic aneurysm in a male current or former smoker
> 70: compression fracture with or without trauma
< 40: ankylosing spondylitis, sensitivity 1.0 but low specificity
Have you been treated with corticosteroids for more Compression fracture: Although insensitive, the specificity of prior steroid use is 0.99 for a
than 1 month? compression fracture.
Do you use injection drugs or have a current Osteomyelitis or paraspinal abscess: although sensitivity is low at 0.40
infection?
Location
Is the pain localized to the back, or does it go Pain remaining above the knee: hip pathology
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elsewhere? Pain radiating down the leg below the knee: sciatica (irritation or compression of the L4–5, S1
Chapter 54. Low Back Pain, M.E. Beth Smith, DO; Roger Chou, MD; Richard A. Deyo, MD, MPH
nerve roots usually from a disk herniation)
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Pain in the abdomen or pelvis: visceral source
Do you use injection drugs or have a current Osteomyelitis or paraspinal abscess: although sensitivity is low at 0.40
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infection?
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Location
Is the pain localized to the back, or does it go Pain remaining above the knee: hip pathology
elsewhere? Pain radiating down the leg below the knee: sciatica (irritation or compression of the L4–5, S1
nerve roots usually from a disk herniation)
Pain in the abdomen or pelvis: visceral source
Description/quality
Is the pain electrical or shocklike? Disk herniation
Is the pain constant and nocturnal? Malignancy when worse with rest
Mechanical when improved with rest
Is the pain colicky? Referred pain from a visceral organ
Does the pain have a tearing or ripping quality? Aortic dissection
Duration/frequency
Was the onset abrupt? Fracture or injury induced
Has the pain been persistent and progressive? > 1 month: malignancy in older patient (sensitivity 0.50, specificity 0.81)
> 3 months: ankylosing spondylitis in younger patient; sensitivity 1.0 but nonspecific (specificity
0.07)
Is the pain cyclical? Endometriosis
Aggravating and relieving factors
Is the pain worse in the morning and associated with Ankylosing spondylitis (sensitivity 0.64, specificity 0.59)
morning stiffness?
Is there pain in the legs with standing that increases Neurogenic claudication from spinal stenosis
with cough or walking?
How does the pain change with forward bending or Improves: spinal stenosis or spondylolisthesis
sitting? Worsens: disk herniation (if promotes sciatica)
Does the pain improve with exercise? Ankylosing spondylitis or nonspecific etiology
Does the pain change in intensity with eating? Improves: peptic ulcer disease
Worsens: pancreatitis, gallbladder disease, or other visceral organ
Associated symptoms
Abdominal pain Visceral etiology
Nausea or vomiting Pancreatitis, peptic ulcer disease, appendicitis
Fever Osteomyelitis, malignancy, or infection related to intraabdominal or pelvic etiology
Predictors of Chronic Disabling Back Pain
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Although most patients with nonspecific back pain have resolution of their symptoms within 6 weeks, 30% to 40% will have recurrences over time, and
approximately 7% will develop chronic LBP that affects their ability to function normally.4,12 A recent systematic review for the Rational Clinical
Nausea or vomiting Pancreatitis, peptic ulcer disease, appendicitis
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Fever Osteomyelitis, malignancy, or infection related to intraabdominal or pelvic etiology
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Predictors of Chronic Disabling Back Pain
Although most patients with nonspecific back pain have resolution of their symptoms within 6 weeks, 30% to 40% will have recurrences over time, and
approximately 7% will develop chronic LBP that affects their ability to function normally.4,12 A recent systematic review for the Rational Clinical
Examination Series in the Journal of the American Medical Association identified features that place an individual at increased risk of developing a
chronic disabling condition.13 By identifying such individuals early, a more proactive approach to management with closer followup may help to
optimize their care.
Median LR Quality of the
Predictors of Worse Outcome at 1 Year
(Range) Evidence
questionnaire)14 2.7)
LR− 0.40
(0.10–0.52)
Diagnostic Approach (Including Algorithm)
When gathering the history from a patient with acute LBP, remember the context. Most LBP is nonspecific and selflimited, so the clinician must identify
individuals with a more worrisome etiology. Serious causes should be considered if there are features suggesting neurologic compromise, a systemic
disease, or referred pain from a visceral organ. Equally important is to identify features that place patients at increased risk of developing a more
chronic and disabling condition, because early intervention may preserve longterm function. See Figure 54–1 for the diagnostic approach algorithm
for low back pain.
Figure 54–1
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chronic and disabling condition, because early intervention may preserve longterm function. See Figure 54–1 for the diagnostic approach algorithm
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for low back pain.
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Figure 54–1
Diagnostic approach: Low back pain. EMG, electromyography; MRI, magnetic resonance imaging.
Caveats
Greater than 90% of acute LBP seen in the primary care setting has a nonspecific, mechanical etiology and will be selflimited.
Neurologic symptoms require assessment for motor or reflex deficits, which, if present, necessitate an urgent or emergent investigation.
Cauda equina syndrome and myelopathy are rare complications that require urgent evaluation. In the absence of urinary retention (often
manifested as overflow incontinence), the likelihood of cauda equina syndrome is about 1 in 10,000. Lumbar myelopathy is suggested by lower
extremity weakness, increased tone, spasticity, and hyperreflexia.
Increasing age, history of cancer, known vascular disease, and associated features such as abdominal symptoms, fever, weight loss, and blood
pressure abnormalities suggest a systemic process or referred pain from a visceral organ.
Patients at heightened risk of developing a chronic and disabling condition may benefit from a multifaceted management approach.
Case Scenario | Resolution
A 51yearold woman presents to your clinic with a complaint of low back pain, which began acutely 2 weeks earlier, 1 day after a 10km run. The pain is
as achy, intermittent, and located in the central region of her low back. It is associated with an occasional electrical sensation shooting down her left
leg. The pain is aggravated by rolling over in bed, prolonged sitting, and running; it is relieved by rest, changing positions, and ibuprofen.
Additional History
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Although it disturbs her training routine, the pain is occasional and dull, allowing her to function normally at work. Her pain is easily relieved by
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changing positions. The shooting pain in her left leg has been improving, no longer occurs daily, and lasts only seconds. She denies any weakness or
numbness, which is confirmed by neurologic examination. Ibuprofen and ice have helped, but primarily she avoids backward bending, running, and
lying prone.
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A 51yearold woman presents to your clinic with a complaint of low back pain, which began acutely 2 weeks earlier, 1 day after a 10km run. The pain is
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as achy, intermittent, and located in the central region of her low back. It is associated with an occasional electrical sensation shooting down her left
leg. The pain is aggravated by rolling over in bed, prolonged sitting, and running; it is relieved by rest, changing positions, and ibuprofen.
Additional History
Although it disturbs her training routine, the pain is occasional and dull, allowing her to function normally at work. Her pain is easily relieved by
changing positions. The shooting pain in her left leg has been improving, no longer occurs daily, and lasts only seconds. She denies any weakness or
numbness, which is confirmed by neurologic examination. Ibuprofen and ice have helped, but primarily she avoids backward bending, running, and
lying prone.
Question: What Is the Most Likely Diagnosis?
A. Spinal stenosis
B. Disk herniation
C. Nonspecific low back pain (LBP)
D. Compression fracture
E. Abdominal aortic aneurysm
Correct answer: C
This patient most likely has nonspecific LBP. Her radiating leg pain is suggestive of radiculopathy and does warrant a comprehensive neurologic
examination, but her lack of motor weakness (confirmed by physical examination) and intermittent nature of her leg pain are reassuring; thus, she can
be treated for nonspecific LBP. She should be encouraged to resume her normal activities and avoid aggravating activities. If her symptoms persist
beyond 4 weeks, physical therapy should be considered. Persistent, bothersome radicular symptoms may warrant magnetic resonance imaging of the
lumbar spine. Her high level of function and low fear of activity place her at low risk of developing a chronic disabling condition.
References
3. Stewart W, Ricci JA, Chee E, et al. Lost productive time and cost due to common pain conditions in the US workforce. JAMA . 2003;290:2443–2454.
[PubMed: 14612481]
5. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a U.S. national
survey. Spine . 1995;20:11–19. [PubMed: 7709270]
6. Stern B, Deyo RA, Rainville J, Bedlack RS. Make the diagnosis: low back pain. In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence
Based Clinical Diagnosis . New York, NY: McGraw Hill, 2009.
7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians
and the American Pain Society. Ann Intern Med . 2007;147:478–491. [PubMed: 17909209]
8. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings
with acute low back pain. Arthritis Rheum . 2009;60:3072–3080. [PubMed: 19790051]
9. Van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in
diagnosing low back pain in general practice. A criteriabased review of the literature. Spine . 1995;20:318–327.
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10. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc
Chapter 54. Low Back Pain, M.E. Beth Smith, DO; Roger Chou, MD; Richard A. Deyo, MD, MPH Page 11 / 12
herniation: a systematic review. J Neurol . 1999;246:899–906. [PubMed: 10552236]
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11. Baumgartner I, Hirsch AT, Abola MT, et al. Cardiovascular risk profile and outcome of patients with abdominal aortic aneurysm in outpatients with
8. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings
with acute low back pain. Arthritis Rheum . 2009;60:3072–3080. [PubMed: 19790051] Universitas Islam Bandung
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9. Van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in
diagnosing low back pain in general practice. A criteriabased review of the literature. Spine . 1995;20:318–327.
10. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc
herniation: a systematic review. J Neurol . 1999;246:899–906. [PubMed: 10552236]
11. Baumgartner I, Hirsch AT, Abola MT, et al. Cardiovascular risk profile and outcome of patients with abdominal aortic aneurysm in outpatients with
atherothrombosis: data from the Reduction of Atherothrombosis for Continued Health (REACH) registry. J Vasc Surg . 2008;48:808–814. [PubMed:
18639426]
12. Carey TS, Garrett JM, Jackman AM. Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain. Spine .
2000;25: 115–120. [PubMed: 10647169]
14. Roland Morris Disability Questionnaire. Available at: http://www.rmdq.org/index.htm. Accessed October 28, 2011.
Suggested Reading
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians
and the American Pain Society. Ann Intern Med . 2007;147:478–491. [PubMed: 17909209]
Stern B, Deyo RA, Rainville J, Bedlack RS. Make the diagnosis: low back pain. In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence
Based Clinical Diagnosis . New York, NY: McGraw Hill, 2009.
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