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Low Back Pain and HIV

for Health Care Providers

Low Back Pain

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

  • Low back pain (LBP) is a common complaint.
  • When evaluating LBP, assess whether the patient has nonspecific LBP, back pain with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. Assess for social or psychological distress that may contribute to chronic, disabling pain.
  • Routine imaging or other diagnostic tests not recommended for nonspecific LBP.
  • Check for red flags and perform diagnostic imaging and testing for: major trauma, age >50, unexplained fever, unexplained weight loss, injection drug use (IDU), immunosuppression, history of cancer, major muscle weakness, bladder or bowel dysfunction, unrelenting night pain, saddle anesthesia, decreased sphincter tone, focal neurologic deficit, duration >6 weeks, abdominal pulsating mass.
  • Up to 90% of patients experiencing acute LBP without sciatica or systemic symptoms improve within 4 weeks.
  • All patients with LBP should receive nonpharmacologic interventions, nonsteroidal antiinflammatory drugs (NSAIDs), or acetaminophen as indicated, and other interventions and medications as necessary. They also should be educated on the expected treatment course, and be advised to remain active.
  • Follow up in 1-3 weeks and as needed. Reevaluate sooner in the event of worsening neurologic symptoms, bowel or bladder dysfunction, systemic symptoms, or failure to improve with initial management.

Background

Epidemiology

  • Back pain is common: In a 2002 U.S. National Health Interview Survey of 30,000 respondents, 26% of adults had back pain lasting at least a whole day during a 3-month period.
  • Back pain is the second most common reason patients in the United States visit their physicians.
  • Back pain can lead to chronic disability. Among patients who have had treatment for back pain, 72% have discontinued exercise and sports because of the pain, 60% have experienced limitations on their activities of daily living, and 46% have reported refraining from sexual activity.
  • The physiologic cause of LBP cannot be definitively established in 85% of patients. Among such patients, LBP has been attributed to disc degeneration or muscular and ligamentous sources.
  • Of patients who have LBP:
    • 70% have lumbar strains or sprains
    • 10% have age-related degenerative processes of discs and facets
    • 4% have herniated discs
    • 3% have spinal stenosis
    • 4% have osteoporotic compression fractures
    • <1% have urgent situations (red flags)

Veterans with HIV*

Lumbago, sciatica, or backache: 25%

*Veterans in the VA HIV Clinical Case Registry in care in 2007 who had an ICD-9 code corresponding to these conditions

Definitions

Acute: duration <6 weeks

Chronic: duration >6 weeks

LBP: pain does not radiate past the knee

Sciatica: pain radiates past the knee along the sciatic nerve (posterior/lateral lower extremity)

Radiculopathy: impairment of a nerve root, usually causing radiating pain, numbness, or muscle weakness that corresponds to a specific nerve root

Cauda equina syndrome: urinary retention with overflow incontinence, saddle anesthesia, bilateral sciatica, and leg weakness; usually caused by a tumor or massive midline disc herniation; represents a medical emergency

Spondylolisthesis: slipping forward of one vertebral body over another; patients may have back or leg pain; rarely, bladder or bowel symptoms or radiculopathic pain

Spondylosis: arthritis of the spine, with radiographically apparent disc space narrowing and arthritic changes at the facet joint; localized pain or spasms with spinal flexion

Spinal stenosis: local, segmental, or generalized narrowing of the central spinal canal by bone or soft tissue; transient tingling in the legs, pain with walking, improvement with rest and with leaning forward; pseudoclaudication with normal distal arterial pulses

Evaluation

Check for red flags:

  • Major trauma
  • Age >50
  • Duration >6 weeks
  • Failure to improve with therapy
  • Unexplained fever
  • Unexplained weight loss
  • IDU
  • CD4 count <200 cells/µL
  • Transplant recipient
  • Steroid use
  • Diabetes
  • History of cancer
  • Major muscle weakness
  • Bladder or bowel dysfunction
  • Unrelenting night pain
  • Saddle anesthesia
  • Decreased sphincter tone
  • Focal neurologic deficit
  • Abdominal pulsating mass

In general, evaluate whether the patient has evidence of systemic disease, neurologic compromise, or social or psychological distress that may contribute to pain. Identify modifiable risk factors that may affect the risk of LBP recurrence.

Use history and examination to place patients into 1 of 3 broad categories:

  • Nonspecific LBP (about 85% of patients)
  • Back pain potentially associated with radiculopathy or spinal stenosis (as suggested by the presence of sciatica and/or pseudoclaudication)
  • Back pain potentially associated with another specific spinal cause (see Red flags below)
Risk factors
  • Obesity
  • Older age
  • Female sex
  • Physically or psychologically strenuous work
  • Sedentary work
  • Job dissatisfaction
  • Smoking
  • Low educational attainment
  • Psychological factors: somatization, anxiety, depression, substance abuse
History
  • Mechanism of onset, trauma
  • Location of symptoms, involvement of legs
  • Duration (acute <6 weeks, chronic >6 weeks)
  • Character of pain: mechanical, radicular, claudicatory
  • Limitations on activity
  • Neurologic symptoms: distribution, bowel or bladder symptoms, weakness, saddle anesthesia
  • Constitutional symptoms: fever, weight loss
  • Night pain
  • Previous spinal surgeries
  • IDU
  • Smoking history
  • Cancer
  • Corticosteroid use
  • Work-related injuries or repetitive stress
  • Psychological stressors, symptoms of anxiety, depression, substance abuse
Example history-taking questions
  • What are your symptoms? (ask about red-flag symptoms)
  • How do these symptoms limit you? How long can you sit, stand, etc?
  • When did the current limitations begin?
  • What do you hope we can accomplish during this visit?
Physical examination
  • Observation of gait, position changes, and stance
  • Inspection of back and posture (scoliosis = lateral asymmetry; kyphosis = posterior convexity; lordosis = lumbar concavity)
  • Range of motion, including lumbar flexion (limited in ankylosing spondylosis)
  • Palpation of the spine (vertebral tenderness suggests fracture or infection)
  • Straight leg raising (SLR): sensitive but not specific for radiculopathy; pain with lifting leg of affected side (from lying position) from 10º to 60º
  • Cross-SLR: specific but not sensitive for radiculopathy; pain with lifting leg opposite affected side (from lying position) from 10º to 60º
  • Neurologic assessment of L4-S1 nerve roots: L4 injury corresponds to reduced unilateral knee extension strength and patellar reflex; L5 injury corresponds to numbness in the medial foot and web space between first and second toes; S1 injury corresponds to reduced unilateral ankle reflex, reduced sensation along the posterior calf and lateral foot; reduced ability to walk on tiptoes for 3 steps
  • Evaluation for malignancy and infection if history and examination suggest a systemic disease (sites of interest include lymph nodes, prostate, breasts)
  • Inconsistent, incongruous, or contradictory physical signs in patients with chronic pain may point to psychological distress
Imaging
  • Imaging is not necessary in the first 4-6 weeks of symptoms unless the patient has red flag symptoms or has any of the following:
    • Progressive neurological findings
    • Constitutional symptoms
    • History of traumatic onset
    • History of malignancy
    • Age ≤18 or ≥50 years
    • Infection risk: IDU, severe immunosuppression, prolonged corticosteroid use, skin or urinary tract infection, indwelling urinary catheter
    • Suspected compression fracture (eg, in persons with osteoporosis or prolonged steroid use)
  • If there is no clinical improvement after 6 weeks, obtain plain anteroposterior and lateral X rays of the lumbosacral spine to evaluate for tumor, infection, instability, spondyloarthropathy, or spondylolisthesis.
  • Computed tomography (CT) or magnetic resonance imaging (MRI) is indicated if there are progressive neurologic deficits or a high suspicion of cancer or infection, and should be considered for patients with >12 weeks of persistent LBP.
  • In patients with persistent LBP and radiculopathy or signs of spinal stenosis, MRI (preferred) or CT is indicated if they are potential candidates for surgery or epidural steroid injection.
Differential diagnosis: Red flags for specific conditions and suggested initial workup
  • Cancer: history of cancer, unexplained weight loss, age >50, pain >6 weeks, night pain

    Evaluation: check CT or MRI of spine, check complete blood count (CBC) and erythrocyte sedimentation rate (ESR), and perform directed evaluation for suspected malignancy (eg, prostate-specific antigen and prostate examination, mammogram, serum protein electrophoresis, urine protein electrophoresis)
  • Infection/osteomyelitis or Pott disease: fever, IDU (consider sacroiliac or verterbral osteomyelitis), tuberculosis exposure risk, recent urinary tract infection, skin infection, pneumonia, corticosteroid use, transplant, diabetes, rest pain

    Evaluation: MRI of the spine, CBC, ESR, urinalysis, blood and urine cultures
  • Cauda equina syndrome: urinary retention or incontinence, saddle anesthesia, decreased anal sphincter tone, bilateral lower extremity weakness/numbness

    Evaluation: immediate surgical consultation
  • Fracture: corticosteroid use, age >70, osteoporosis, recent trauma

    Evaluation: plain X rays or CT, orthopedic consultation
  • Acute abdominal aneurysm: pulsating abdominal mass, vascular disease, resting or night pain, age >60

    Evaluation: ultrasound or CT to evaluate aorta, surgical consultation
  • Significant herniated nucleus pulposus: major muscle weakness

    Evaluation: MRI of the spine and surgical consultation

Management

  • Up to 90% of patients with LBP without sciatica or systemic symptoms have nonspecific LBP and improve within 4 weeks of starting treatment.
  • Recurrences are common, occurring in up to 40% of patients within 6 months after initial resolution.
  • Goals of management are to reduce pain and disability using conservative measures and to identify patients with more serious conditions that need further care.
  • All patients with LBP should get nonpharmacologic interventions and move up the analgesic and intervention "ladder":
    • acetaminophen or NSAIDs +/- adjuvants →
    • weak opioids +/- adjuvants →
    • strong opioids +/- adjuvants
  • Acetaminophen and NSAIDs are first-line medications for most LBP.
  • For chronic and subacute back pain, studies suggest that antiepileptic drugs, muscle relaxants, benzodiazepines, and opiates show insufficient evidence of effectiveness to be recommended as treatment.
Table 1. Nonpharmacologic and Pharmacologic Interventions
InterventionComments

(Print table)

Nonpharmacologic
  • Patient education
  • Activity modification
  • Exercise
  • Physical therapy
  • Self-application of heat or cold to back
  • Manipulation
  • Other options
  • Patient education topics include expectations for rapid recovery, avoiding worry, coping with having a sore back, methods of symptom control, activity modifications, recognition of certain red-flag symptoms, and follow-up.
  • Patients should be encouraged to walk and resume normal daily activities as soon as possible.
  • Limit bed rest as much as possible. Patients who go on longer bed rest have less improvement in pain and function than those who remain ambulatory.
  • Activity modification should be minimal for acute back pain: Modifications might include limiting prolonged unsupported sitting, avoiding heavy lifting, and avoiding bending or twisting the back when lifting.
  • Maintain or start aerobic conditioning exercises, including swimming, walking, and stationary biking.
  • Avoid physical therapy for 2 weeks after onset of acute back pain.
  • Conduct workplace ergonomics evaluation if the back pain is related to work activities.
  • Manipulation may be helpful in the first month of symptoms for selected patients who do not have radiculopathy or severe or progressive neurologic deficits. Refer to practitioners with specific training in manipulation (eg, osteopathic physicians).
  • For chronic LBP, the following have shown moderate effectiveness, with best effectiveness when regimens are tailored to each patient?s individual needs and preferences:
    • Acupuncture
    • Exercise therapy
    • Massage therapy
    • Yoga
    • Cognitive-behavioral therapy or progressive relaxation
    • Spinal manipulation
Pharmacologic
(for dosages and additional information, see Pain Medications)
Acetaminophen
  • First-line analgesic because of its safety profile.
  • Use for patients who cannot tolerate NSAIDs.
  • Possible adverse effects include hepatotoxicity (especially if taken with alcohol) and nephrotoxicity (with chronic overdose).
NSAIDs
(eg, ibuprofen, naproxen)
  • First-line analgesic.
  • May not confer additive benefit when used with high-dose acetaminophen.
  • Avoid use for patients with peptic ulcer disease or cirrhosis.
  • Monitor for nephrotoxicity.
  • May increase risk of cardiovascular events: rofecoxib (COX-2 inhibitor) was withdrawn from the market owing to observational data showing greater risk than celecoxib; diclofenac confers greater risk than other nonselective NSAIDs.
Tricyclic antidepressants (TCAs)
(eg, amitriptyline, nortriptyline)
  • Consider for neuropathic pain; also consider as an adjunct for any type of subacute or chronic LBP unresponsive to acetaminophen and NSAIDs.
  • Anticholinergic and other adverse effects, especially at higher dosages.
Muscle relaxants
(nonbenzodiazepines)
  • Cyclobenzaprine
  • Baclofen
  • May be useful as adjunctive therapy for acute back pain but not recommended for chronic or subacute back pain.
  • Short-term (1-3 week) use.
Benzodiazepines
  • May be useful as adjunctive therapy for acute back pain but not recommended for chronic or subacute back pain.
  • Second-line muscle relaxant after cyclobenzaprine or baclofen.
  • No data is available comparing the relative efficacy and safety of the various benzodiazepines
  • A time-limited course (1-3 weeks) is recommended, owing to the risk of abuse, addiction, and tolerance.
Epidural steroid injections
  • Medications may include corticosteroids, lidocaine, and opioids
  • For short-term relief of radicular pain; consider after failure of conservative treatment.
  • Epidural steroid injections have not been shown to reduce the rates of subsequent disc surgery.
  • Refer to back pain specialist or orthopedist.
Opiate analgesics
  • Options include:
    • Tramadol
      (not a typical opiate; exact mechanism of action is unknown; acts in part as a central opioid agonist)
  • Weak opioids
    • Codeine
    • Hydrocodone + acetaminophen
    • Oxycodone + acetaminophen

  • Strong opioids
    • Morphine
    • Oxycodone
    • Hydromorphone
    • Fentanyl transdermal
  • Consider opioids for patients who have severe pain refractory to the interventions listed above (nonpharmacologic and pharmacologic) or cannot receive those therapies.
  • For very short-term use in severe acute exacerbations, and for severely disabling chronic back pain; start with weak opioids; assess safety, efficacy, and usage; titrate up and move to strong opioids as needed.
  • Use the lowest effective dosage.
  • If needed for acute flares, limit use to a designated short period of time.
  • If needed for chronic pain, try to use a sustained-release opioid with scheduled dosing around the clock, with shorter-acting opioids for breakthrough pain as needed.
  • Risk of dependence, overdose: monitor closely.
  • Adverse effects include oversedation, hypotension, respiratory depression, central nervous system stimulation or somnolence, dizziness, constipation, nausea, and pruritus.
  • Note that tramadol 37.5 mg + acetaminophen 325 mg has shown pain relief equivalent to codeine 30 mg + acetaminophen 325 mg but with fewer side effects (major side effect: headache).
  • Chronic opioid therapy should incorporate an opioid use agreement that includes functional goals for outcome, not reduced pain intensity alone.

When to Refer

Refer immediately to Orthopedic Surgery or Neurosurgery for:

  • Cauda equina syndrome
  • Spinal cord compression
  • Progressive or severe neurologic deficit

Consider referral to Orthopedic Surgery or Neurosurgery for patients with persistent LBP or sciatica caused by:

  • Disc herniation
  • Spinal stenosis
  • Spondylolisthesis

Consider referral to Physiatry for patients who are not improving:

  • Chronic back pain <6 weeks
  • Chronic sciatica <6 weeks
  • Chronic pain syndrome
  • Recurrent back pain

Consider referral to Neurology for:

  • Chronic sciatica >6 weeks
  • Atypical chronic leg pain (negative SLR)
  • New or progressive neuromotor deficit

Consider referral to Rheumatology for patients with persistent symptoms to:

  • Rule out inflammatory arthropathy
  • Rule out fibrositis/fibromyalgia
  • Rule out metabolic bone disease (eg, osteoporosis)

Prevention

  • Conduct ergonomic evaluation of work areas and implement ergonomic design of job tasks.
  • Exercise has shown benefit in preventing first episodes of back pain, preventing recurrences after episodes of back pain (initiate exercise after episode is complete), and reducing the perception of back pain.

Follow-Up

  • Follow up in 1-4 weeks with a phone call or visit and as needed. Follow-up is necessary when there is worsening of neurologic symptoms, bowel or bladder dysfunction, presence of systemic symptoms, or failure to improve with initial management.

References