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.
- 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.
- 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%
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
Check for red flags:
- Major trauma
- Age >50
- Duration >6 weeks
- Failure to improve with therapy
- Unexplained fever
- Unexplained weight loss
- CD4 count <200 cells/µL
- Transplant recipient
- Steroid use
- 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)
|Example history-taking questions|
|Differential diagnosis: Red flags for specific conditions and suggested initial workup|
- 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.
(for dosages and additional information, see Pain Medications)
(eg, ibuprofen, naproxen)
|Tricyclic antidepressants (TCAs)|
(eg, amitriptyline, nortriptyline)
|Epidural steroid injections|
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
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)
- 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 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.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number 14. Rockville, MD: U.S. Department of Health and Human Services; December 1994.
- Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. 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 Oct 2;147(7):478-91.
- Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000396.
- VA/DoD Clinical Practice Guideline Working Group. Diagnosis and Treatment of Low Back Pain. Washington, D.C.: Department of Veterans Affairs, Office of Quality and Performance; July 2008.
- World Health Organization. Treatment and Care of Injecting Drug Users; Module 10: Managing Pain in HIV-Infected Injecting Drug Users, 2007. Jakarta: ASEAN Secretariat; 2007. Accessed August 14, 2008. [Page 13 has useful charts on the WHO analgesic ladder and equivalent opiate doses.]