C H A P T E R 47 
Musculoskeletal Back Pain
PRINCIPLES
Background
Back pain is one of the most common patient complaints encoun-
tered in emergency departments (EDs). Approximately two-thirds
of adults are affected by back pain at some point in their lives,
making it the second most common complaint in ambulatory
medicine and the third most expensive medical disorder following
cancer and heart disease. Most cases of musculoskeletal back
pain are related to physical motion of the vertebrae and muscu-
lature of the back, including muscle strain, ligamentous injury,
vertebral misalignment, and intervertebral disk disease, although
a precise pathoanatomic diagnosis can be found only about 15%
of the time.
Back pain complaints are the most prevalent and expensive
cause of work-related disability in the United States. Back pain has
been reported at least once in 85% of adults, and 15% to 20% of
Americans complained of at least one episode of back pain yearly.
Chronic back pain and low back pain syndromes can lead to
significant loss of work productivity.1
Back pain presents the emergency clinician with a challenging
diagnostic dilemma. Although most causes of acute or acute-on-
chronic back pain are not precisely identifiable, certain causes of
back pain require timely diagnosis and intervention.
Epidemiology
Back pain is a common complaint among men and women and
most frequently occurs in people from 30 to 50 years old.2-4
Smokers have increased incidence of back pain, although no
causative link has been identified, and the association is higher in
the adolescent age range.5
Anatomy and Physiology
Musculoskeletal back pain derives from pathology in the thoracic
or lumbar spine and its associated muscles, nerves, and soft tissue
structures. The thoracic spine consists of twelve thoracic verte-
brae. The lumbar spine consists of five lumbar vertebrae and the
sacrum and ends in the coccyx. The sacrum and coccyx are each
composed of five small fused vertebrae. The vertebrae are con-
nected by the anterior longitudinal ligament (ALL), the posterior
longitudinal ligament (PLL), and the ligamentum flavum. The
vertebrae articulate with each other at facet joints, where an
inferior articular process from each vertebral body pairs with a
superior articular process from the vertebral body below it bilater-
ally, creating four facet joints at each level. The thoracic vertebral
bodies also have bilateral rib facets, which articulate with 12 pairs
of ribs, whereas the lumbar vertebral bodies do not. Additionally,
each vertebral body has bilateral transverse processes and a
spinous process. Between the spinous process and the transverse
processes are the lamina, and between the transverse processes
and the posterior aspect of the vertebral body are the pedicles.
Together, the pedicles and lamina form the neural arch, which,
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Amita Sudhir | Debra Perina
along with the posterior aspect of the vertebral body, forms the
confines of the vertebral canal that contains the spinal cord and
nerve roots. At each level, there are intervertebral (neural) foram-
ina, bounded by pedicles superior and inferiorly, facet joints
posteriorly, and the vertebral body anteriorly. These provide a
route for the exit of spinal nerves.
Between the vertebral bodies are the intervertebral discs, which
provide elasticity and stability to the spine. Each disc is comprised
of the outer annulus fibrosis, a ring of fibrous tissue, and the inner
nucleus pulposus, a collagenous substance. The vertebral bodies
and discs are connected by the PLL and the ALL. The ALL prevents
hyperextension of the spine, whereas the PLL limits flexion of the
spine. The spinous processes are connected by the supraspinous
and interspinous ligaments. The ligamentum flavum connects the
lamina posteriorly and helps maintain disc tension. The inter-
transverse ligament connects transverse processes on either side
of the spine and limits lateral movement. Finally, the iliolumbar
ligament stabilizes the lumbosacral joint.
Movements of the spine are governed by extensor muscles,
found in the back—forward flexors, which are the abdominal wall
muscles and the psoas and iliacus; lateral flexors, which are the
quadratus lumborum assisted by abdominal wall muscles; and
rotators, which are really the extensors and lateral flexors used
unilaterally.
The spinal cord runs continuously from the foramen magnum
to the L1 to L2 interspace. The spinal cord may sometimes be as
low as L3. At this point, it splits into the cauda equina. It is sur-
rounded by three membranes—the tough dura mater, and the
more delicate arachnoid and pia mater (the leptomeninges). The
epidural space, between the bony vertebral canal and the dura,
contains connective tissue padding and the spinal venous plexus.
The dural sac ends between S1 and S3. The dura also protects the
spinal nerve roots as the nerves exit the spine. Between the arach-
noid and pia mater cerebrospinal fluid bathes the spinal cord. At
each level of the spine, nerves exit the cord and the cauda equina
just below the correspondingly numbered vertebral body, for
example L1 nerves exit bilaterally just below the L1 vertebral body.
There are twelve thoracic nerve pairs, five lumbar nerve pairs, and
five sacral nerve pairs. The spinal nerves give rise to sinuvertebral
nerves, which provide sensory innervation to the meninges, the
periosteum, and the PLL and ALL. The discs themselves have little
innervation.
Pathophysiology
Uncomplicated Back Pain
In as many as 85% of patients, no pathologic cause for back pain
can be identified. In these patients, pain is presumed to be from
the soft tissue structures supporting the spine, primarily muscles
and ligaments. Sprains and strains of the thoracic and lumbar
paraspinous muscles can occur, as can ligamentous strain. These
patients typically have localized pain and no radiation of pain or
paresthesias to the lower extremities.6
569
570 PART II  Trauma  |  SECTION Two  Orthopedic Lesions
Nerve Root Syndromes
Nerve root syndromes occur when there is compression or irrita-
tion of the nerve root, leading to pain, which often radiates down
a leg, and paresthesias. There are multiple possible etiologies for
nerve root syndromes.
As one ages, intervertebral discs desiccate and degenerate and
the nucleus pulposus herniates outward, compressing the nerve
root as the nerve exits the foramen.
Herniations tend to occur mainly at the L4 to L5 and L5 to S1
levels. This is because most flexion and extension of the spine
occurs at the lumbosacral joint and to a lesser degree at L4 to L5.
Additionally, the PLL is weak at this level of the spine. Disc hernia-
tion accounts for only 4% of acute back pain cases. Approximately
95% of patients with disk herniation have sciatica. Thus, only
about 1 out of 500 patients with acute back pain but without
sciatica symptoms will have a herniated disc as the cause.
The annulus fibrosis may tear without a true herniation of the
nucleus pulposus. This can result in nerve root irritation rather
than a true compression syndrome, and pain may radiate down
the leg but not below the knee.
Although most disc herniations are posterolateral, discs some-
times herniate centrally, at the level of the cauda equina, causing
severe compression of multiple nerve roots, resulting in cauda
equina syndrome (CES). This results in spinal cord compression
below the termination at the conus medullaris and loss of func-
tion of the lumbar plexus. This presents symptomatically as back
pain that radiates to both legs, saddle anesthesia, and loss of bowel
or bladder function. Saddle anesthesia involves the S3, S4, and S5
dermatomes, and it manifests clinically by numbness or tingling
to the perineum, anus, and genitalia.7 Decreased rectal muscle
tone causes loss of bowel function. Bladder dysfunction generally
takes the form of inability to urinate, which may manifest as
overflow incontinence as a result of urinary retention. CES may
also be caused by compressive lesions other than a herniated
disc, including severe spinal stenosis, malignancy, infection,
hemorrhage, or fracture.
Nerve compression can also be caused by spinal stenosis. Aging
causes the disc space to narrow but also deteriorates the joints in
the spine. Osteophytes form at the facet joints, and the ligamen-
tum flavum calcifies. These changes lead to narrowing of the
neural foramina and the central canal with nerve root compres-
sion from osteophytes and increased intrathecal pressure in the
narrowing canal. Pain is often bilateral, unlike impingement from
a herniated disc. It also results in leg pain that typically worsens
with walking that can be temporarily relieved if the person flexes
forward slightly at the waist, relieving pressure on the nerve root,
allowing further ambulation for a short period of time. This is
known as the pseudoclaudication sign.
Spinal epidural abscess causing CES or other nerve root symp-
toms is a rare but an important emergency. An abscess develops
in the epidural space, usually from hematogenous spread of
bacteria (often staphylococcal species), related to intravenous (IV)
drug use or a recent tattoo. Patients can also develop epidural
abscess from direct inoculation, such as an epidural steroid injec-
tion or recent spinal surgery. An epidural hematoma may present
similarly, usually resulting from instrumentation of the epidural
space or recent surgery, although it can occur spontaneously in a
patient taking anticoagulants.
Skeletal Causes
Fractures may occur in any part of the spine secondary to trauma
(see Chapter 36). Although a significant amount of force, either
direct, axial loading, or flexion/distraction injury, is required to
fracture a normal spine, patients with osteopenia secondary to age
or chronic steroid use may sustain a fracture with little to no
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trauma. The incidence of vertebral compression fractures increases
with advancing age. Even with the advancing age of general popu-
lation, vertebral fracture accounts for less than 5% of acute back
pain. In patients older than 50 years old, compression fracture
may be the cause of sudden onset of acute back pain. Compression
fracture may occur without trauma or injury. Spontaneous frac-
tures generally present as compression fractures of the thoracic or
lumbar vertebral bodies, whereas traumatic fractures may occur
in any bony part of the vertebral column. Fractures may present
with or without radicular symptoms, depending on the location
of the injury and impingement on the spinal canal or nerve roots
by a fracture fragment.8
Like epidural abscess, osteomyelitis of the spine can be caused
by hematogenous spread by bacteria. Pain is caused by inflamma-
tion of bone and periosteum and may or may not be associated
with other manifestations of infection, such as fever. Again, IV
drug use is a risk factor, as is direct bacterial infection from spinal
surgery. Tuberculosis can also be a cause of osteomyelitis of the
spine (Pott’s disease).
Cancer in the spine is usually a metastatic lesion from another
source, but primary bone tumors in the spine can also occur.
Primary tumors are usually found in patients younger than 30
years old and involve the posterior vertebral elements. Primary
spinal tumors include multiple myeloma, Ewing’s sarcoma, and
osteosarcoma, but primary lesions are 25 times less common than
metastatic disease. Metastatic tumors more typically involve the
vertebral body. Unlike many other causes of back pain, metastatic
spinal lesions are more likely to be found in the thoracic spine
(about 70%) than in the lumbar vertebrae. Metastasis is usually
by the hematogenous route, and multiple levels are often involved.
Lung and breast cancers make up over 50% of metastatic spinal
lesions. Lymphoma, melanoma, cancers of the gastrointestinal
(GI) tract, prostate, and kidney, and multiple myeloma may also
present as metastatic spinal lesions. Of note, intramedullary and
extramedullary metastases may also occur but are less common
than bony metastases.
Skeletal back pain may also be caused by nontraumatic con-
genital or acquired abnormalities of the spine. Spondylolisthesis,
or slippage of one vertebral body on another, causes back pain
when the displacement is backward (retrolisthesis) but not when
it is forward (anterolisthesis). Spondylolisthesis is usually the
result of degenerative changes but may follow a traumatic event.
Facet arthropathy, also a result of aging, may also be a cause of
back pain. Inflammatory arthropathies, such as ankylosing spon-
dylitis and rheumatoid arthritis, may cause the same changes in
the spine as osteoarthritis and may also results in pathologic
fractures.
CLINICAL FEATURES
History
A thorough history and a directed physical examination will, in
most cases, guide the clinician to the correct diagnosis and will
allow differentiation between simple musculoskeletal pain and
more sinister diagnoses. The patient is asked to describe the
current episode: onset; duration; severity; character of the pain
(burning, shooting, dull or sharp, constant or intermittent); loca-
tion, including presence of any abdominal or flank pain; and
radiation. Radiation of the pain to the lower extremity is another
important feature of the history. Pain that radiates below the knee
is more likely to be radicular. Pain that does not radiate is more
likely muscular in origin. Pain that radiates, but not below the
knee, may suggest an annular ligament tear.
Aggravating factors are also important. Pain that increases with
increasing intrathecal pressure (such as, coughing, sneezing, or
bearing down with bowel movements) increases the likelihood of

a radicular or spinal cause. Pain that is worse with walking or
prolonged standing, or pseudoclaudication, particularly if relieved
by bending forward, suggests spinal stenosis. Pain that is worse in
the mornings and improves through the day suggests a rheumatic
etiology.
The patient is asked about neurologic findings (such as, numb-
ness or weakness), pain in other parts of the spine, and whether
there is bowel or bladder dysfunction. Next, seek the nature and
timing of any prior episodes of back pain and any history of back
trauma, malignancy, systemic symptoms (fever, chills, malaise,
nausea, generalized myalgia), spinal surgery or procedures (eg,
epidural injection), and anticoagulant use. Medications are
reviewed, particularly corticosteroid use, which may point to an
underlying inflammatory cause, and also can cause osteopenia
with increased likelihood of fracture. Family history is rarely
contributory, but history of autoimmune inflammatory diseases
and malignancy may be helpful.
Physical Examination
The patient is undressed and placed in a gown. Inspection of
the overlying skin for changes such as erythema, warmth, or swell-
ing is supplemented by a general observation of the patient’s
wellness, degree of discomfort, and presence of any generalized
skin changes, such as jaundice, rash, or multiple bruises. The
patient ambulates and the gait should is observed. Range of
motion includes flexion and extension at the waist (entire spine),
lateral flexion (mostly thoracic spine), and rotation (exclusively
thoracic spine). This is also a good time to examine for scoliosis,
which may be longstanding or acute secondary to muscle spasm.
Next, palpation in the location of the pain may identify areas
of maximal tenderness or the presence of muscle spasm. Strength
testing of the lower extremities is best done with the patient
standing. The patient is instructed to flex both hips and knees,
assuming a partial sitting position, then to lift one leg briefly,
then the other. Walking on heels and on toes (while holding
the examiner’s hands) requires full plantar and dorsiflexion
strength, because the entire body weight is carried on a single
extremity. If the patient is not able to comply with this testing
because of pain, strength testing can be performed with the
patient lying down, but it is not as reliable. Sensory testing is done
with the patient lying down or sitting. Testing should include the
upper extremities, because some conditions, such as spinal steno-
sis, may occur at multiple levels of the spine and may involve the
cervical spine as well. A thorough neurologic examination can
help the clinician determine if multiple levels of the spine need to
be imaged.
Straight leg raise and crossed leg raise tests are important in
determining if the pain is radicular. The straight leg raise test is
more sensitive but less specific than the contralateral straight leg
raise test for the diagnosis of radiculopathy due to disc hernia-
tion.9,10 The straight leg raise test is performed as follows:
• With the patient supine and legs extended, the examiner raises
the each leg, flexing at the hip with the knee in extension.
• The patient is completely passive for this examination, and the
quadriceps should not be engaged.
• This can be determined by noting that the patella can be
moved freely move side to side.
• A positive result is pain radiating from the back to a point
below the knee of the raised leg at 30 to 40 degrees of elevation.
A positive result predicts L5 or S1 radiculopathy with a sensi-
tivity of approximately 90% and a specificity of 30% or lower.11
Because these two discs are implicated in 95% of disc hernia-
tions, this is a highly useful test, and a negative result is reassuring
in ruling out disc pathology. Radiation of pain from the back to
the area of the posterior knee or above is a nonspecific finding of
no clinical value.
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CH APTER 47  Musculoskeletal Back Pain 571
The contralateral leg raise test is performed in an identical
manner. A positive finding is pain that radiates below the knee of
the contralateral leg (the leg that is not being raised). The sensitiv-
ity of this test for disc herniation is poor, below 25%, but specific-
ity approaches 100%.11 This makes a positive test result strongly
suggestive of disc pathology at the L5 or S1 levels. If one has a
positive straight leg raise test, a positive contralateral straight leg
raise test can be considered confirmatory of the presence of a
ruptured disc. If the contralateral straight leg raise is positive with
a negative straight leg raise test, disc herniation is still highly likely
due to the high specificity of the contralateral test.
Patellar and Achilles deep tendon reflexes should be elicited
and the plantar reflex assessed. Hyperreflexia, clonus, or a Babinski
sign (positive plantar reflex) suggests upper motor neuron pathol-
ogy, such as a cord impingement or malignancy.
Perineal sensation and anal sphincter tone are assessed in
patients with bilateral symptoms or findings, gait disturbance,
severe pain, complaints of saddle anesthesia, or bowel or blad-
der dysfunction. Bladder dysfunction is evaluated by post-void
ultrasonographic measurement of bladder volume. A completely
normal bladder should have about 20 cc of residual urine after
voiding, and anything over 100 cc is considered abnormal. If
bedside ultrasound is not available, post-void residual is measured
by in-and-out urinary catheterization.
Because pain from abdominal or pelvic pathology often radi-
ates to the back, a thorough abdominal examination, including
assessing for costovertebral angle tenderness and, where indicated,
a prostate or gynecologic examination should be performed to
rule out non-musculoskeletal causes of low back pain.
DIFFERENTIAL DIAGNOSES
Table 47.1 lists the various causes of low back pain along with
findings on the history that point toward the specific cause of back
pain. In constructing a differential diagnosis, the clinician incor-
porates history and physical examination finding, particularly
whether there is evidence of a nerve root cause for the pain, or
findings to suggest infection or malignancy. Radicular pain is
most often due to true herniated discs. Classic presentation
includes decreased sensation in a dermatomal distribution cor-
responding to the level of the involved disc along with motor
weakness and reflex loss (Table 47.2). However, herniated discs
can present with only a positive straight leg raise test (see earlier
discussion).
DIAGNOSTIC TESTING
Laboratory Testing
Laboratory testing is rarely indicated for low back pain. When
spinal epidural abscess is suspected, prompt imaging is required,
although a white blood cell (WBC) count, erythrocyte sedimenta-
tion rate (ESR) and C-reactive protein (CRP) should be obtained
in parallel with the imaging plan. The WBC count is often
obtained when infection is suspected but is neither sufficiently
sensitive nor specific to confirm or exclude any particular diag-
nosis. The presence of an elevated ESR significantly increases the
suspicion for a spinal epidural abscess, osteomyelitis, or discitis.
Marked elevations in the ESR are more often due to infection than
other causes, but noninfectious disorders such as malignancy,
chronic diseases, inflammation, trauma, and tissue ischemia are
also common etiologies. ESR values of over 100 mm/hour are
most likely due to infection, whereas lower values suggest myriad
causes, of which infection is just one. CRP is both less sensitive
and specific than ESR, but it may add some diagnostic information
when elevated. Markedly elevated levels of CRP are strongly asso-
ciated with infections with values in above 10 mg/dL (100 mg/L).
572 PART II  Trauma  |  SECTION Two  Orthopedic Lesions

TABLE 47.1  BOX 47.1 

Historical Clues to the Cause of Low Back Pain Indications for Advanced Imaging Studies
QUESTIONS FOR PATIENT POTENTIAL DIAGNOSIS
History of malignancy
Does the back pain radiate down past Radiculopathy and likely a Fever with localized back pain
the knees? herniated disk Back pain with history of intravenous (IV) drug use, recent tattoo, or
Is the pain worse with walking and Spinal stenosis bacterial source
better with bending forward and sitting? New neurologic deficit (especially loss of bowel or bladder function or
saddle anesthesia)
Do you have morning back stiffness that Ankylosing spondylitis Direct trauma
improves with exercise? Worsening pain after spinal surgery
Are you older than 50 years old? Osteoporotic fracture, spinal Sudden onset of back pain in patients on anticoagulants
malignancy Recent spinal procedure, such as epidural injection
Has there been any recent history of Fracture
blunt trauma?
Do you take long-term corticosteroids? Fracture, spinal infection
Do you have a history of cancer? Spinal metastatic malignancy origin. A urine pregnancy test should be obtained when imaging
is indicated in a woman of childbearing age or if back pain is felt
Does your pain persist at rest? Spinal malignancy, spinal to be of pelvic origin.
infection
Has there been persistent pain for longer Spinal malignancy Imaging Studies
than 6 weeks?
Most patients with back pain require neither plain radiographs
Has there been unexplained weight loss? Spinal malignancy
nor advanced imaging. Routine imaging for low back pain is not
Is the pain worse at night? Spinal malignancy, spinal associated with an improvement in patient outcomes. Even when
infection abnormalities are found, they are often incidental and not the
Are you immunocompromised (eg, HIV Spinal infection cause of presenting symptoms.13,14 Imaging in the setting of acute
infection, alcoholism, diabetes)? pain should be reserved for patients with suspected diagnoses that
would necessitate emergency management.12 Signs, symptoms,
Have you had fevers or chills? Spinal infection and historical features that should lead the clinician to consider
Do you have pain, weakness, or CES imaging studies are provided in Box 47.1.
numbness in both legs?
Do you have bladder or bowel control CES Plain Radiographs
problems?
In general patients with nontraumatic low back pain with a
CES, Cauda equina syndrome; HIV, human immunodeficiency virus. normal neurological examination do not need plain radiographs
in the ED. Clinicians may obtain plain radiographs when there is
concern for occult spontaneous compression fractures in patients
with nontraumatic back pain who have osteopenia or are taking
TABLE 47.2  chronic steroids. If ESR or CRP tests are elevated, plain films
should not be obtained, and one should proceed directly to
Physical Findings Corresponding to Herniated advanced imaging. In cases where there is a history of low energy
Disc Location traumatic injury (such as, ground level fall or low speed motor
PAIN SENSORY REFLEX vehicle collision), plain radiographs of the affected area of the
LEVEL LOCATION MOTOR LOSS LOSS LOSS spine are sufficient to identify or exclude significant fractures.
Elderly patients are at particular risk for occult fractures with
L3 Front of leg Hip flexion and Anterior thigh, Loss of minor trauma, and the clinician should obtain plain films in the
knee extension medial calf knee jerk ED when localized pain or tenderness is present, even with low
L4 Front of leg Leg extension Around knee Loss of energy mechanisms. Anteroposterior and lateral views of the
at knee knee jerk thoracic and lumbar spine are usually sufficient in the ED to
evaluate for acute factures. Oblique views show the pars interar-
L5 Side of leg Foot dorsiflexion Web of big toe No reflexes
lost
ticularis in profile and may help in the diagnosis of spondylolysis.
In general, oblique views do not add additional information and
S1 Back of leg Foot plantar Lateral foot Loss of significantly increase the dose of radiation. These views, therefore,
flexion ankle jerk are not recommended for routine evaluation. Flexion/extension
views may be helpful in patients who have had surgical fusion
procedures to evaluate for slippage or fracture of hardware. Plain
radiographs of the chest may also be helpful, particular in the
Coagulation testing is indicated for patient taking long-term setting of thoracic back pain, because rib fractures can be detected
anticoagulants. If the prothrombin time (PT) or international and may be the cause of pain referred to the back. The sensitivity,
normalized ratio (INR) is excessively elevated in the setting of specificity, and diagnostic accuracy of plain films and advanced
low back pain complaints, one should consider a spontaneous imaging techniques for spine trauma are discussed in Chapter 36.
epidural or retroperitoneal bleed.12 In nontrauma cases, advanced neuroimaging is indicated when
Urinalysis may also be helpful when the problem is not clearly localizing signs and symptoms suggest possible epidural abscess,
musculoskeletal, because low back pain in women can be of pelvic mass, or hematoma, osteomyelitis or discitis, or CES, or when

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there are new significant neurological deficits or unexplained
neurological findings. Computed tomography (CT), magnetic
resonance imaging (MRI), and CT myelogram are the most com-
monly used modalities, and each is further discussed in the fol-
lowing sections.
Computed Tomography
CT is preferable to MRI for bony anatomy abnormalities. If a
fracture is present on plain films, CT can better delineate the
nature and extent of the fracture. In patients with higher pre-test
probability of fracture (ie, those with a significant injury mecha-
nism, on chronic steroid therapy, or with point tenderness directly
on a thoracic or lumbar vertebra), the clinician should omit plain
radiographs and proceed directly to CT scan. In a multi-trauma
patient undergoing CT scans of the chest and abdomen, views of
the thoracic and lumbar spine can be reconstructed from these
studies, and dedicated plain films are not necessary. CT has
superior sensitivity for detecting abnormalities of cortical bone
over MRI, which cannot directly visualize cortical bone. Therefore,
when bony injury or lesions are suspected, CT is preferable over
MRI. The converse is true when soft tissue pathology, including
spine and nerve roots, is suspected.
Magnetic Resonance Imaging
MRI is the test of choice for evaluating the spinal cord and the
spinal structures, including the canal, intervertebral discs, and soft
tissue, including ligaments and epidural space. MRI defines the
bony anatomy and visualizes soft tissues and neural structures,
such as the conus medullaris and spinal nerve roots within the
canal and neural foramina. It provides axial as well as sagittal
views, which can demonstrate pathologic discs, ligaments, nerve
roots, and epidural fat, as well as the shape and size of the spinal
canal. MRI is both more sensitive and specific than plain radio-
graphs for the detection of spinal infection and malignancy, and
it is the modality of choice in back pain patients with elevated ESR
or CRP. Emergent MRI is indicated for suspected CES, epidural
hemorrhage, or history of malignancy with sudden onset or
worsening of pain accompanied by new neurological findings.
MRI helps delineate many etiologies of back pain, including epi-
dural hematoma or abscess, herniated disc, ligamentous injury,
and spinal stenosis, and it is the test of choice for diagnosing
osteomyelitis. MRI may also help to determine the chronicity of
a fracture. For example, if a plain film, or even CT, demonstrates
a compression fracture but there was no inciting trauma or the
history is unclear, MRI may help delineate whether the fracture is
acute. However, for acute fractures, CT is still the imaging modal-
ity of choice. Contrast administration provides little additional
information to the MRI and is unnecessary unless either new
spinal symptoms arise postoperatively or there is a question of
intraspinal infection or metastasis.
In evaluating for spinal cord lesions, the clinician must make
a decision about which spinal levels to include. A thorough neu-
rologic examination that includes upper extremities may be used
to exclude the C spine from imaging, but it is important to
remember that spinal processes (such as, malignancy or stenosis)
can occur simultaneously in several levels, and the region of pain
may not always correspond to the lesion causing a neurologic
deficit. Cervical or thoracic spine lesions may cause lower extrem-
ity deficits. For this reason, consideration should be given to
imaging the entire spine.
Computed Tomography Myelogram
Myelography is rarely performed in current practice and generally
used in patients who need advanced imaging but are not able to
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CH APTER 47  Musculoskeletal Back Pain 573
have an MRI, such as those with implanted hardware (pacemaker,
spinal hardware, deep brain stimulator) or retained metal frag-
ments from previous surgery or injuries. Because of the theoretical
increased risk of seizure during this procedure, emergency clini-
cians should be aware of medications the patient is taking that
lower seizure threshold, such as tramadol. If on these medications,
some centers require that they be held for 24 to 72 hours before
the test can be performed. Clinicians should discuss medications
with their consulting radiologist before ordering this test.
MANAGEMENT
Figure 47.1 presents and algorithmic approach to ED manage-
ment of patients with low back pain based on physical and/or
ancillary test findings.
Uncomplicated Back Pain
Initial therapy for uncomplicated back pain focuses on pain
control to maximizing return to function.1 Treatment in the ED
is directed at supportive care and symptomatic relief. In patients
with mild to moderate pain and adequate function (can get up
and down off the bed and walk unaided), initial therapy is an oral
nonsteroidal antiinflammatory drug (NSAID) in analgesic doses
(eg, ibuprofen 400 to 600 mg every 4 hours), or acetaminophen
1000 mg every 4 to 6 hours, if the patient is NSAID intolerant.15
For patients with severe pain or muscle spasm that significantly
affects normal daily function and with a normal neurologic
examination, oral analgesia with an NSAID, as mentioned earlier,
is supplemented by an oral opioid medication, such as oxycodone
5 to 10 mg, with observation for improvement over a 2-hour
period. There is no proven benefit of ongoing opioid analgesic
therapy, and opioid prescriptions at discharge should provide
coverage only for 24 to 72 hours to mitigate the acute pain and
improve sleep, movement, and ambulation. Combination therapy
with NSAIDs and opioids, as compared to NSAIDs alone, does
not appear to improve functional outcomes or pain at 1-week
follow-up.16,17 Similarly, there is no proven benefit of “muscle
relaxant” medications, such as cyclobenzaprine or carisoprodol,
and these agents have very significant side effect profiles. We do
not recommend their use, either in the ED or as a discharge
prescription. A benzodiazepine may be prescribed to supplement
the analgesic regimen when the patient has failed an appropriate
regimen or when the pain is causing substantial anxiety or sleep
disturbance. Once the patient’s symptoms are improving, the
patient is discharged on an appropriate pain regimen, guided by
the results in the ED. Wherever possible, outpatient management
should be achieved with NSAID medication alone, although some
patients with severe pain may require a short course (3 days) of
opioid medication as well.18
Bed rest is not recommended. Patients without sciatic symp-
toms benefit from staying active, and patients with sciatic symp-
toms are likely to experience no difference in pain from bed rest
versus staying active.19
Early return to work, with or without activity restrictions, is
associated with better long-term outcomes. Patients may also
experience benefit from gentle stretching exercises. Physical
therapy, although not associated with improved outcomes for
uncomplicated back pain, is associated with improved patient
satisfaction. A referral to physical therapy may be made in the ED
or by the patient’s primary care physician.20 Seventy percent of
patients achieve improvement within 1 week.21,22 Only about 10%
of all patients have long-term issues, often because of functional
overlay. Chronic back pain is more likely to develop in patients
with psychiatric disorders, poor overall health status, and nonor-
ganic signs. Development is not associated with demographic
variables, prior episodes of back pain, or baseline pain levels.23
574 PART II  Trauma  |  SECTION Two  Orthopedic Lesions

Back pain

Initial ED management:
• NSAIDs
• Muscle relaxants
• Consider opioids
• Single dose steroids

No neurologic deficit or
Significant Sensory findings only
neurologic deficit
or
Abnormal PVR

Afebrile: Febrile or
• CES Infection concern:
• Tumor • Epidural abscess
• Hematoma • Osteomyelitis
• Fracture
Positive radiograph: Negative radiograph or
not indicated:
• Traumatic fracture
• Herniated disc
• Pathologic fracture
Broad spectrum • Sciatica
Empirical steroids • Muscle strain
Antibiotics

Positive MRI: Muscle relaxants

• Emergent spine consultation NSAIDs
• Possible surgery Flexion/extension exercises
• Hospital admission PCP follow-up

Fig. 47.1.  Algorithmic approach to emergency department (ED) management of low back pain. CES,
Cauda equina syndrome; MRI, magnetic resonance imaging; NSAID, nonsteroidal antiinflammatory drug;
PCP, primary care physician; PVR, post-void residual.

Disk Herniation from a single pulse dose of 6 to 10 mg of IV dexamethasone in

Herniated disks are commonly managed initially like lumbosacral
strain with no imaging indicated and symptomatic treatment
provided. Signs and symptoms that indicate the need for advanced
imaging include new bowel or bladder dysfunction, new localized
motor weakness, progressive leg weakness, or acute and substantial
worsening of symptoms or findings in patients with known herni-
ated discs or chronic back problems. Indications for emergent
spine service consultation include rapidly progressive neurologi-
cal symptoms or signs of acute cord compression, including CES.
Nerve Root Pain
Patients with nerve root or sciatic pain and no neurologic deficits
should be treated similarly to those with uncomplicated back
pain. Oral steroids do not improve recovery for unselected patients
with acute back pain.24 However, there is evidence that the subset
of patients with nerve root pain and acute radiculopathy benefit
the ED.25 Alternatively, a 15-day course of a tapering dose of
prednisone (60 mg, 40 mg, 20 mg daily for 5 days each) improves
function but without improvement in pain.23
Epidural Abscess and Spinal Osteomyelitis
Epidural abscess is a surgical emergency. Emergent spine surgery
consultation should be obtained; or if not possible at the treating
hospital, the patient should be transferred to a facility with
spine surgery available. Empirical antibiotics should also be
administered to cover suspected pathogens, usually Staphylococ-
cus, Streptococcus, and gram-negative species. Because of increas-
ing rates of methicillin-resistant Staphylococcus aureus (MRSA)
infection, vancomycin should be included in the antibiotic regi-
ment. Pseudomonal coverage should be considered when the
infection is felt to be due to hematologic spread, particularly in
diabetic patients and those with sickle cell disease. Antibiotics
should be directed against the known pathogen if the culture or

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Gram stain of the aspirate is positive. Appropriate empirical
parenteral regimens include:
• Vancomycin (30 to 60 mg/kg IV per day in two equally divided
doses adjusted for renal function) for empirical coverage of
MRSA
plus
• Metronidazole (500 mg IV every 8 hours)
plus
• Either cefotaxime (2 g IV every 6 hours), ceftriaxone (2 g IV
every 12 hours), or ceftazidime (2 g IV every 8 hours): Ceftazi-
dime is preferable when Pseudomonas aeruginosa is considered
a possible or likely pathogen.
In some cases, especially where MRI shows minimal cord
impingement, conservative management with antibiotics alone
and no surgery may be considered.
Osteomyelitis also requires antibiotics with coverage for similar
bacterial pathogens, along with surgical consultation. The need
for surgery may be less emergent than with epidural abscess if
there is no mass effect on the cord or purulent fluid collection.
Whenever possible, antibiotic therapy should be delayed in stable
patients until tissue cultures can be obtained. If tissue culture is
not obtainable and in advance of tissue culture results, broad-
spectrum empirical therapy should be administered. Empirical
inpatient antibiotics commonly include:
• Inpatient treatment:
• Nafcillin (2 g every 4 hours) for methicillin-sensitive
Staphylococcus aureus (MSSA) coverage
or
• Vancomycin (30 to 60 mg/kg IV per day in two equally
divided doses adjusted for renal function) for empirical
coverage of MRSA
or
• Cefepime (2 g IV every 8 to 12 hours) for gram-negative
and Pseudomonas coverage
• Outpatient treatment:
• Ciprofloxacin (750 mg by mouth BID)
or
• Trimethoprim-sulfamethoxazole (1 double-strength tablet
twice daily)
Epidural Hematoma
Although rare, the diagnosis of epidural hematoma should result
in emergent spinal surgical consultation. Additionally, patients
on anticoagulant should have their anticoagulation reversed as
described in Chapter 114. Because of the danger of hematoma
expansion, consultation should be obtained rapidly and all neces-
sary steps taken to facilitate rapid operative intervention.
Cauda Equina Syndrome
CES, when suspected, requires rapid confirmation and, if con-
firmed, emergency decompression, usually by surgery, is the usual
course of action. Emergency medicine and radiology departments
should collaborate on the development of a CES imaging protocol
that gives immediate priority to patients clinically suspected of
CES and ensures the most rapid possible completion of MRI
imaging and expert interpretation. Whenever possible, the emer-
gency spine surgery consultation should be obtained in parallel
with the ordering of the imaging study so that plans can be
established in the event the diagnosis is confirmed by imaging.
Although prompt surgery provides the best opportunity for a
good outcome, some patients may not recover function even
after decompressive surgery; and in patients with longstanding
or chronic symptoms of CES, surgery may be deferred. Planning
with respect to emergency surgical intervention occurs in consul-
tation with spine surgery. Some clinicians initiate IV corticosteroid
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CH APTER 47  Musculoskeletal Back Pain 575
therapy when the diagnosis of CES is strongly suspected or con-
firmed; however, multiple clinical trials have failed to identify
convincing evidence of greater or more rapid recovery of function
with this practice. The risk of a single dose of corticosteroids is
very low. We recommend that corticosteroids not be used in CES
unless ordered by the treating spine surgeon.
Malignancy
If malignancy is diagnosed on plain film or advanced imaging
but the patient is neurologically intact and pain can be well
controlled, management may be continued as an outpatient.
However, patients with compressive malignant lesions of the spine
or spinal cord may benefit from emergent corticosteroids to
reduce the severity of mass effect. A single dose of 10 mg IV
dexamethasone is the steroid of choice, and it is administered
when new neurologic findings suggest an acute compressive
malignant lesion.26 However, the effects are transient, and surgical
decompression may be required. Additionally, radiation oncology
consultation is sought to determine whether emergency decom-
pressive radiation therapy is indicated. This can be done in con-
junction with oncology or surgical consultation.
Fracture
The management of acute traumatic spinal fractures is discussed
in Chapter 36.
DISPOSITION
The vast majority of patients presenting to the ED with acute back
pain will be discharged with symptomatic treatment and an
appropriate follow-up plan. For most, follow-up with a primary
care physician is adequate. If the patient has no radicular findings,
then that the clinician should explain to the patient why imaging
is not helpful and that the pain will likely resolve with conservative
measures. Work notes may help patients limit heavy lifting or
significant time on their feet. Patients should also be counseled
that despite being provided medications, acute back pain is
unlikely to resolve quickly and may take days or weeks to signifi-
cantly improve. Setting an expectation for the time frame for
improvement may reduce the likelihood of a quick return to the
ED for unchanged symptoms. Patients with suspected radiculopa-
thy should also be given clear return precautions, including the
development of weakness, inability to stand or ambulate, saddle
anesthesia, or bowel or bladder dysfunction.
For those with back pain thought to be secondary to a com-
pressive lesion (such as, a herniated disc) and non-emergent
sensory or motor findings (see earlier discussion), follow-up
should occur in 3 to 7 days with the primary care physician or a
spine surgeon. This is the case for patients who did not have
imaging, or imaging was performed but did not identify an urgent
surgical lesion. When imaging is not obtained, the patient is
counseled that imaging will not likely be required in future unless
symptoms persist or worsen over several weeks. Studies of the
benefits of interventions (such as, epidural steroid injection) have
provided mixed results, but discussion of such therapy is the
domain of the spine consultant on an outpatient basis.
Patients who require emergent surgical intervention for spinal
epidural abscess, neoplasm, osteomyelitis, fracture, or other
compressive spine lesions should be transferred to the care of a
spine surgeon emergently, which may involve transfer to a tertiary
care center.
Transfer may also be necessitated by the non-availability
of MRI or CT myelography in patients in whom an emergent
infectious or compressive etiology is strongly suspected. Patients
576 PART II  Trauma  |  SECTION Two  Orthopedic Lesions

believed to have an epidural abscess or osteomyelitis should findings consistent with CES or other compressive lesions due to
receive empirical parenteral antibiotics as detailed in Epidural malignancy should receive parenteral steroids prior to transfer if
Abscess and Spinal Osteomyelitis section earlier. Patients with ordered by the receiving physician or the onsite consultant.

KEY CONCEPTS
• Most back pain presenting to the emergency department (ED) is
benign, self-resolving with conservative therapy, and does not require
imaging.
• Indications for emergent imaging include history of malignancy, new
significant neurologic deficit, bowel or bladder dysfunction or saddle
anesthesia, intravenous (IV) drug use, fever, immunocompromised
state, chronic steroid use, and anticoagulant use.
• Metastatic disease is more common than primary tumors in the
spine, and thoracic metastases are more common than lumbar
metastases.
• Epidural abscess or hematoma, cauda equina syndrome (CES), spinal
malignancy with compressive symptoms, and spinal osteomyelitis are
indication for emergent surgical consultation or transfer to a center
where emergent surgical consultation is available.
• Empirical parenteral antibiotics active against staphylococci,
streptococci, and gram-negative bacilli should be administered for
suspected epidural abscess. Antibiotics should be directed against the
known pathogen if the culture or Gram stain of the aspirate is
positive.
• Corticosteroids given as a single dose in the ED (10 mg
dexamethasone) or as a 15-day tapering course after discharge
(prednisone 60 mg, 40 mg, 20 mg daily for 5 days) may improve
functional ability but do not improve pain for patients with nerve
root findings related to disc herniation.
• Corticosteroids are of no proven benefit for patients with CES. We
recommend that corticosteroids not be used for patients with
suspected or known CES unless desired by the treating spine
surgeon.

The references for this chapter can be found online by accessing the accompanying Expert Consult website.

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11. van der Windt DA, Simons E, Riphagen II, et al: Physical examination for lumbar
radiculopathy due to disc herniation in patients with low-back pain. Cochrane
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back pain in the United States emergency departments: a national perspective. Spine
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13. Chou R, Qaseem A, Owens DK, et al: Diagnostic imaging for low back pain: advice
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CHAPTER 47: QUESTIONS & ANSWERS
47.1. A 55-year-old man presents with the complaint of low
back pain for 1 month. The pain is worse at night and is
associated with a 10-pound weight loss. He denies any
radicular symptoms. Which of the following is the most
likely cause of this man’s back pain?
A. Chordoma
B. Lymphoma
C. Multiple mieloma
D. Osteosarcoma
E. Sciatica
Answer: B. The patient’s subacute time course of back pain and
worrisome finding of weight loss suggest a malignancy. Primary
and metastatic bone neoplasms can cause back pain from tumor
infiltration into the bone. Primary bone tumors, such as multiple
myeloma, chordoma, Ewing’s sarcoma, and osteosarcoma, are 25
times less frequent than metastatic disease. Of the neoplasms,
breast, lung, prostate, thyroid, lymphoma, and kidney are the
most likely to metastasize to bone.
47.2. Which one of the following indicates a benign
presentation of back pain?
A. Low back pain and fever
B. Low back pain and saddle anesthesia
C. Low back pain in a 6-year-old child
D. Low back pain with a negative sitting but a positive
supine straight leg raise (SLR) test
E. Low back pain with post-void residual of 500 mL
Answer: D. A positive supine SLR test but a negative sitting SLR
test suggests a nonphysiologic cause for the pain. Low back
pain and fever suggest an epidural abscess or spondylitis. Saddle
anesthesia and post-void residual greater than 100 mL are indica-
tive of cauda equina syndrome (CES). Children complaining of
back pain must be investigated. They may have spondylolysis
with varying degrees of spondylolisthesis, Scheuermann’s disease
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reserved.
CH APTER 47  Musculoskeletal Back Pain 576.e1
15. Cho R: Pharmacological management of low back pain. Drugs 70(4):387–402, 2010.
16. Friedman BW, Dym AA, Davitt M, et al: Naproxen with cyclobenzaprine, oxycodone/
acetaminophen or placebo for treating acute low back pain: a randomized clinical
trial. JAMA 314(15):1572–1580, 2015.
17. Deyo RA, VonKorff M, Duhrkoop D: Opioids for low back pain. BMJ 350:g6380,
2015.
18. Goertz M, Thorson D, Bonsell J, et al: Adult acute and subacute low back pain,
Bloomington (MN), 2012, Institute for Clinical Systems Improvement (ICSI). Avail-
able at: <www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog
_guidelines/catalog_musculoskeletal_guidelines/low_back_pain/>.
19. Dahm KT, Brurberg KG, Jamtvedt G, et al: Advice to rest in bed versus advice to stay
active for acute low-back pain and sciatica. Cochrane Database Syst Rev (6):CD007612,
2010.
20. Edlow JA: Managing nontraumatic acute back pain. Ann Emerg Med 66(2):148–153,
2015.
21. Friedman BW, O’Mahony S, Mulvey L, et al: One week and 3 month outcome after
an emergency department visit for undifferentiated musculoskeletal low back pain.
Ann Emerg Med 59(2):128–133e3, 2012.
22. Freidman BW, Mulvey L, Davitt M, et al: Predicting 7 and 3 month functional out-
comes after and ED visit for acute nontraumatic low back pain. Am J Emerg Med
30(9):1852–1859, 2012.
23. Goldberg H, Firtch W, Tyburski M, et al: Oral steroids for acute radiculopathy due
to a herniated lumbar disc: a randomized clinical trial. JAMA 313(19):1915–1923,
2015.
24. Eskin B, Shih RD, Fiesseler FW, et al: Prednisone for emergency department low back
pain: a randomized control trial. J Emerg Med 47:65–70, 2014.
25. Balakrishnamoorthy R, Horgan I, Perez S, et al: Does a single dose of intravenous
dexamethasone reduce symptoms on emergency department patients with low back
pain and radiculopathy (SEBRA)? A double bind randomized controlled trial. Emerg
Med J 32:525–530, 2015.
26. Thiruganasambandarmoothy V, Turko E, Ansell D, et al: Risk factors for serious
underlying pathology in adult emergency department nontraumatic low back pain
patients. J Emerg Med 47:1–11, 2014.
(kyphosis and osteochondritis of the vertebral end plates), infec-
tious diseases, or neoplastic etiologies.
47.3. The adult spinal cord usually ends at which level?
A. L1 to L2
B. L3 to L4
C. L5 to S1
D. S2 to S3
E. Coccyx
Answer: A. The spinal cord ends at around L2 in adults, lower in
children. Remember that between individuals, there may be sig-
nificant anatomic variance.
47.4. A 55-year-old man complains of low back pain when
walking downhill that is relieved with walking uphill. His
neurovascular examination is unremarkable except for
decreased bilateral Achilles reflexes. What is the
appropriate management of this patient?
A. Lumbosacral radiographs
B. Magnetic resonance imaging (MRI)
C. Pain management and bed rest
D. Pain management and emergent surgical consultation
E. Pain management and surgical referral for
pseudoclaudication
Answer: E. This patient presents with typical complaints of spinal
stenosis. Patients with spinal stenosis should be managed conser-
vatively with pain medications. In the absence of alarming red flag
findings, these patients do not require laboratory or radiographic
studies in the emergency department (ED). These patients may be
candidates for surgery if they show any of the following condi-
tions: progressive neurologic deficit, progressive reduction in
ability to walk secondary to pseudoclaudication, evidence of
cauda equina syndrome (CES), or intractable pain.
576.e2 PART II  Trauma  |  SECTION Two  Orthopedic Lesions

47.5. Which of the following statements regarding cauda equina
syndrome (CES) is false?
A. Hallmarks are saddle anesthesia and urinary retention
B. Is often caused by a central disk herniation
C. Is most often associated with a post-void urinary
residual of 75 mL or less
D. Requires emergency surgical decompression
E. Usually compresses bilateral nerve roots
Answer: C. The most consistent examination finding in CES is
urinary retention. With a high sensitivity of 90%, the patient is
unlikely to have this disease process if his or her post-void residual
urine volume is less than 100 to 200 mL. Saddle anesthesia
(sensory deficit over the buttocks, upper posterior thighs, and
perineal area) is frequently an associated finding, with a sensitivity
of 75%. In 60% to 80% of cases, the rectal examination reveals a
decreased sphincter tone.
47.6. A 42-year-old man presents to the emergency department
(ED) with a 12-day history of low back pain after an
episode of heavy lifting at work. He reports bilateral low
back pain at the level of the iliac crests. He denies sensory
or motor symptoms. He also denies bowel or bladder
dysfunction. His neurologic examination is normal. For
this patient, which are the most important treatments and
recommendations?
A. Lumbar MRI
B. Lumbar MRI, complete blood count (CBC), and
erythrocyte sedimentation rate (ESR)
C. Obtaining lumbar radiographs with anteroposterior,
lateral, and oblique views
D. Placement on strict bed rest for 4 weeks
E. Treatment with symptomatic medication and return to
light activity
Answer: E. The patient most likely suffers from idiopathic low
back pain. This is also commonly called acute lumbosacral strain.
Most patients with this injury should not be placed on bed rest
and should be allowed to return to normal activity, possibly with
some restrictions. The patient has a relatively short history of low
back pain with clear onset around an episode of lifting. Given a
lack of concerning historical or examination findings, the patient
does not require imaging at this time. Blood work would not be
of help in evaluating the patient, because he lacks history or
examination findings consistent with spinal infection.
47.7. A 35-year-old woman presents with a 3-day history of
severe right lower extremity pain associated with mild
low back pain. Her neurologic examination is normal
except for a positive straight leg raise (SLR) test on the
right and a negative cross straight leg raise (CSLR) test on
the left. What is the most likely source of this patient’s
symptoms?
A. Acute lumbosacral strain
B. Ankylosing spondylitis
C. Lumbar disk herniation with radiculopathy
D. Spinal epidural abscess
E. Spinal malignancy
Answer: C. Patients with herniated lumbar disks often present
with radicular leg pain that overshadows the complaint of back
pain. It is very common for a patient with lumbar radiculopathy
to have no clear motor or sensory deficit but have exacerbation of
leg pain with SLR testing. The SLR has high sensitivity but low
specificity. In contrast, the CSLR test has high specificity but low
sensitivity. Given this, it is common for the patient with lumbar
disk herniation to have a positive SLR but negative CSLR. The
reverse is very uncommon. Diagnoses (such as, spinal epidural
abscess and spinal malignancy) usually present with prominent
low back pain that is more significant than extremity pain.
47.8. A 68-year-old man presents with a 5-week history of
worsening low back pain. He reports mostly midline
spinal pain with occasional radiation into both lower
extremities. Two weeks before the onset of his pain, he
was discharged from the hospital after an inpatient stay
for pneumonia. On examination, he has intact lower
extremity motor and sensory function but tenderness to
percussion over the lumbar spine. Initial evaluation of the
patient is most likely to reveal which of the following?
A. Lumbar computed tomography (CT) showing
degenerative spondylolisthesis at L4 to L5
B. Lumbar magnetic resonance imaging (MRI) showing
unilateral L4 to L5 disk herniation
C. Lumbar MRI showing very large central disk
herniation at L4 to L5 with compression of the cauda
equina
D. White blood cell (WBC) count of 9000 and erythrocyte
sedimentation rate (ESR) of 58
E. WBC count of 22,000 and ESR of 4
Answer: D. The patient’s history is suspicious for spinal epidural
abscess. He is at higher risk because of his age and recent infection.
In addition, the patient has tenderness with percussion of his
spine. Patients with epidural abscess usually have an ESR elevated
above 20 mm/hr. However, it is not uncommon for them to have
a normal or only mildly elevated WBC count. It would be uncom-
mon for the patient to have an elevated WBC count but normal
ESR. Lumbar disk herniation is rarely associated with spinal
tenderness to percussion. A large central disk herniation with
bilateral nerve root compression would likely present with lower
extremity symptoms. Degenerative spondylolisthesis at L4 to L5
would likely be an asymptomatic problem.
47.9. A 63-year-old man presents with a 9-month history of
progressive low back pain with ambulation. He reports
significant pain in his buttocks and posterior thighs when
he walks distances greater than 25 meters. He says the
pain is partially relieved when he flexes forward and
completely relieved by recumbency. He reports the pain is
not relieved if he stops walking but remains standing. On
neurologic examination, he has intact lower extremity
strength but diminished Achilles reflexes bilaterally. Other
likely findings include which of the following?
A. Diminished posterior tibial and dorsalis pedis pulses
B. Lumbar magnetic resonance imaging (MRI) revealing
right L5 to S1 disk herniation
C. Lumbar MRI revealing spinal stenosis at L4 to L5 and
L5 to S1
D. Normal lumbar MRI
E. Thoracic MRI revealing significant T5 to T6 disk
herniation with spinal cord compression
Answer: C. The patient presents with classic findings of spinal
stenosis and neurogenic claudication or “pseudoclaudication,”
including relief with flexing forward and recumbency. Persistence
of pain with standing despite having stopped ambulating is also
indicative of neurogenic claudication, as are diminished Achilles
reflexes. Diminished pulses are indicative of vascular claudication.
Pain from vascular claudication is generally relieved if a patient
stops walking but remains standing. Unilateral disk herniation
does not usually present with bilateral lower extremity symptoms.
Spinal cord compression from T5 to T6 disk herniation would
cause myelopathy and generally present with gait unsteadiness
and hyperreflexia but not pain.

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