Back Pain

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 Back Pain Red Flags
• In actual practice => Data for using “red flags” is limited

• On exams => Lower the threshold for early imaging/intervention

• Red flags:
• Age > 50
• Fever or weight loss
• Saddle anesthesia
Order an MRI!
• Point tenderness to percussion
• Positive straight leg raise
• Anticoagulation (e.g. Warfarin)
• Trauma
• Steroid use
• History of cancer

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 Back Pain: High-Yield
• Back Strain
Other Etiologies:
• Herniated Disc • Back Trauma (e.g. Central
Cord Syndrome)
• Spinal Stenosis • Upper extremity nerve
palsies (e.g. Cervical
• Ankylosing Spondylitis spondylopathy)
• Atlantoaxial instability
• Epidural Abscess

• Spinal Epidural Hematoma

Non-spinal Etiologies:
• Vertebral Metastasis • Pancreatitis
• Kidney stones
• Multiple Myeloma • Pyelonephritis
• Abdominal aortic aneurysm
• Vertebral Compression Fracture • Zoster

• Spinal Cord Compression

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 Back strain
• Presentation: Back pain after trauma, lifting, overuse
• Worse with activity, better with rest

• Pathophysiology: Muscle strain

• Dx: Straight leg test => Negative crossed-leg sign

• ↑ focal back pain, but NO radiation
• Paraspinal tenderness +/- spasm

• Mgmt: NSAIDs, Physical activity

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 Herniated Disc
• Presentation: Back pain after exertion w/ radiation to the foot on one

side
• Worsened by coughing, Valsalva
• May progress to Cauda Equina syndrome

• Pathophysiology: Herniated nucleus pulposus => L5-S1 nerve root

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 Herniated Disc
• Dx: Straight leg test => Positive crossed-leg sign
• Pain radiating down the leg on the side of the non-raised leg

• Mgmt: NSAIDs, Acetaminophen, Physical activity

• If refractory, progressive, or “red flags” => MRI
• +/- Discectomy

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 Spinal Stenosis
• Presentation: Low back pain + pain in the legs with activity
• May be referred to buttock/thigh
• Worse with extension, standing, walking
• Relieved with flexion (leaning on shopping cart, walking upstairs, biking)
• Neurogenic Claudication vs. Vascular Claudication

• Pathophysiology: Degeneration => Narrowing of spinal canal

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 Spinal Stenosis
• Dx: Exam => Pain w/ back extension
• MRI (Best test)

• Mgmt:
• 1. Physical therapy, NSAIDs
• 2. Corticosteroid injections
• 3. Laminectomy

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 Ankylosing Spondylitis
• Presentation: Caucasian male <40 years old with slow-onset back pain
• Worst in the morning, improves with activity
• ↓ flexion, ↓ chest expansion
• Systemic manifestations: Anterior uveitis, Pulmonary Fibrosis, Heart block
• Enthesitis

• Pathophysiology: Autoimmune

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Ankylosing Spondylitis
“Bamboo spine”

CC (0): Public Domain

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 Ankylosing Spondylitis
• Dx: X-ray => “Bamboo spine” + Fusion of sacroiliac joints
• Positive for HLA-B27
• Negative for RF, ANA
• ↑ ESR, CRP

• Mgmt: Physical therapy, NSAIDs

• If no improvement in 4-6 weeks => X-ray of spine and sacroiliac joints
• Disease-modifying agents: Methotrexate, TNF-ɑ inhibitors, Sulfasalazine

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 Epidural Abscess
• Presentation: IVDU w/ subacute onset of back pain + fever
• Diabetic or alcoholic with cellulitis, osteomyelitis, or epidural injection
• Bilateral symptoms in the lower extremities, bowel/bladder dysfunction

• Pathophysiology: Staph aureus

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 Epidural Abscess
• Dx: MRI w/ contrast
• ↑ WBC, ESR, CRP, Temperature (vs. Epidural hematoma)

• Mgmt: CT-guided aspiration to determine antibiotic regimen

• Surgical decompression

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 Spinal Epidural Hematoma
• Presentation: Subacute back pain in a patient on anticoagulation
• Recent back procedure: Epidural, Lumbar puncture, Surgery
• As hematoma grows => Progressive motor and sensory symptoms

• Pathophysiology: Venous bleed

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 Spinal Epidural Hematoma
• Dx: MRI w/ contrast
• Lack of fever or systemic symptoms (vs. Epidural abscess)

• Mgmt: Surgical decompression

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 Vertebral Metastasis
• Presentation: Pain worse at night, NO change w/ activity
• History of cancer or systemic symptoms/weight loss
• May present as a stress fracture

• Pathophysiology: Hematogenous spread

• Lytic OR Blastic (i.e. Prostate)

CC (0): Public
Domain

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 Vertebral Metastasis
• Dx: X-ray

• Mgmt:
• +/- Chemotherapy
• +/- Palliative radiation
• +/- Opioids (Take cancer pain SERIOUSLY)

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 Multiple Myeloma
• Presentation: Older male with back pain and hypercalcemia
• Fatigue
• Weight loss
• Recurrent infections

• Pathophysiology: Plasma cell neoplasm

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 Multiple Myeloma
• Dx/Mgmt: SPEP/UPEP => M-spike (IgG)
• BMP => Hypercalcemia
• CBC => Normocytic anemia
• X-ray => Osteolytic lesions
• Peripheral blood => Rouleau formation
• Bone marrow biopsy (BEST test) => 10%+ clonal plasma cells

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 Vertebral Compression Fracture
• Presentation: Older female
• Acute: Pain w/ decreased ROM and pain w/ movement
• Chronic: Progressive, painless kyphosis

• Pathophysiology: Osteoporosis
• Trauma
• Malignancy (i.e. metastatic)
• Hyperparathyroidism
• Chronic corticosteroids

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 Vertebral Compression Fracture
• Dx: X-ray
• If neurologic findings => MRI

• Mgmt: Acetaminophen, Ibuprofen, Naproxen

• Resume physical activity
• Bisphosphonates
• Surgery

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 Spinal Cord Compression
• Presentation: Severe localized back pain
• Early => LE weakness, ↓ DTRs
• Late => + Babinski, Sensory loss, ↓ Rectal tone, ↑ DTRs

• Pathophysiology:
• Trauma
• Malignancy
• Infection

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 Cauda Equina vs. Conus Medullaris
Cauda Equina Syndrome
• Presentation: Slower-onset back
pain w/ radiation to lower
extremities
• Saddle anesthesia
• Asymmetric weakness
• Hyporeflexia
• Late bowel/bladder incontinence
• Path: Compression of cauda
equina roots
Conus Medullaris Syndrome
• Presentation: Acute focal pain
w/out radiation
• Perianal anesthesia
• Symmetric weakness
• Hyperreflexia w/ Erectile dysfunction
• Early bowel/bladder incontinence
• Path: Compression of tapered
conus
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 Vertebral Metastasis
• Dx: Immediate MRI

• Mgmt: If malignant compression => IV Methylprednisolone

• Emergency surgery (within 48 hours)

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 Back Pain: High-Yield
• Back Strain
Other Etiologies:
• Herniated Disc • Back Trauma (e.g. Central
Cord Syndrome)
• Spinal Stenosis • Upper extremity nerve
palsies (e.g. Cervical
• Ankylosing Spondylitis spondylopathy)
• Atlantoaxial instability
• Epidural Abscess

• Spinal Epidural Hematoma

Non-spinal Etiologies:
• Vertebral Metastasis • Pancreatitis
• Kidney stones
• Multiple Myeloma • Pyelonephritis
• Abdominal aortic aneurysm
• Vertebral Compression Fracture • Zoster

• Spinal Cord Compression

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