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Back Pain

Author: Vincent E. Casiano Author: Gurpreet Sarwan Author: Alexander M. Dydyk Editor: Matthew Varacallo Updated: 12/11/2023 12:18:48 AM

Introduction

Back pain is one of the most common reasons for primary- and emergency-care consultations. An estimated $200 billion is spent annually on managing back pain. Additionally, work hours, productivity, and workers' compensation are greatly reduced due to this condition.[1]

Back pain arises from a broad range of causes in adults and children, though most are mechanical in nature or have a nonspecific origin. Mechanical back pain comprises 90% of cases, so health providers can easily miss rare causes while focusing on common etiologies.[2][3] 

Identifying red flags and determining the appropriate treatment are the most important aspects of back pain management. Most cases can be managed conservatively. Association with nerve dysfunction and other alarming signs warrants a thorough investigation and a multidisciplinary approach.[4]

Pharmacological treatments include pain relievers targeting peripheral and central neurologic pathways and muscle relaxants.[5] Various forms of physical therapy are available for individuals who prefer nonpharmacological approaches or recovering from injuries.[6] Acupuncture is an alternative therapy shown to improve back pain moderately. Surgery is reserved when the symptom is accompanied by severe nerve dysfunction or is due to serious causes like malignancy.[7][8] Back pain that does not resolve 6 weeks after acute injury warrants imaging by radiography, computed tomography (CT), or magnetic resonance imaging (MRI).

A thorough evaluation helps determine the cause of back pain and develop a tailored therapeutic plan. Eliminating the cause of this symptom profoundly improves patients' functional capacity and quality of life.

Etiology

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Etiology

Back pain arises from various conditions, which can be classified into the following:[9]

  • Traumatic: Back pain commonly results from direct or indirect contact with an external force. Examples are whiplash injury, strain, and traumatic fractures.
  • Degenerative: Musculoskeletal structures can weaken over time due to aging, overuse, or pre-existing pathology. Conditions like intervertebral disk herniation and degenerative disk disease fall into this class.
  • Oncologic: Anatomic structures of the back can develop primary or secondary malignant lesions. Pathologic fractures of the axial skeleton can arise as a complication.
  • Infectious: Infections of the musculoskeletal structures in this region can arise from direct inoculation or spread from another source.
  • Inflammatory: This category includes inflammatory conditions not caused by infection or malignancy. Examples are ankylosing spondylitis and sacroiliitis. Chronic inflammation can give rise to spinal arthritis.
  • Metabolic: Calcium and bone metabolism can cause the symptoms. Osteoporosis and osteosclerosis are examples.
  • Referred pain: Visceral organ inflammation can cause referred back pain. Examples are biliary colic, lung disease, and aortic or vertebral artery pathology.
  • Postural: Spending long hours in an upright position can cause back pain. Pregnancy and certain occupations can predispose people to postural back pain.
  • Congenital: Inborn conditions of the axial skeleton can cause the symptoms. Examples are kyphoscoliosis and tethered spinal cord.
  • Psychiatric: Back pain may also present in patients with chronic pain syndromes and other mental health conditions. Malingering individuals may also claim to have back pain.

The problem's duration must also be considered, as acute back pain often has different sources from chronic back pain. Thorough clinical evaluation and appropriate diagnostic examination are usually enough to determine the exact cause of this symptom. Depending on the findings, referral to specialists such as orthopedic surgeons, neurologists, rheumatologists, or pain management specialists may be necessary for further evaluation and treatment planning.

Epidemiology

Back pain is widespread among adults. Studies show that up to 23% of adults worldwide suffer from chronic low back pain, with one-year recurrence rates reaching 24% to 80%.[10][11]. Lifetime back pain prevalence is as high as 84% in adults.[12]

Back pain is less prevalent among pediatric patients than in adults. One Scandinavian study revealed that the point prevalence of back pain was approximately 1% for 12-year-olds and 5% for 15-year-olds. By age 18 for girls and age 20 for boys, 50% would have already experienced at least one episode of back pain.[13] The lifetime prevalence of back pain in adolescents increases steadily with age until it approximates adult levels by 18 years.[14]

History and Physical

Determining the cause of back pain starts with a thorough history and physical examination. The onset of the pain must be established early. Acute back pain, which lasts less than 6 weeks, is usually precipitated by trauma or sudden changes in the course of a chronic illness like malignancy. Chronic cases, which last longer than 12 weeks, may be mechanically related or due to longstanding conditions.

Information about what provokes or alleviates the pain must be elicited. Besides providing additional clues to the diagnosis, knowing these factors guides the clinician in determining the appropriate pain control measures for the patient.

The pain quality helps the provider distinguish between visceral and non-visceral pain. Well-localized pain is often an indicator of an organic process. Any associated symptoms can serve as further clues about the source of back pain.

Other pertinent information may be obtained from the patient's medical, family, occupational, and social history. For example, a history of previous cancer chemotherapy should raise suspicion of metastasis or a secondary tumor. Some autoimmune arthritides have a hereditary component. Pott disease or spinal tuberculosis can result from tuberculosis exposure while traveling to a location where the infection is endemic. Spending long hours in a sitting position at work can cause acute and chronic back pain.

A focused physical examination should include inspection, auscultation, palpation, and provocative maneuvers. Visual back inspection may not reveal the cause of the problem unless deformity, inflammation signs, and skin lesions are present. Auscultation is valuable when the back pain may be secondary to a pulmonary pathology. Palpation can elicit localized musculoskeletal tenderness. 

Some provocative exercises can help provide clues about the cause of back pain. One is the straight-leg-raising (SLR) test, which is useful for diagnosing lumbar disk herniation. The test is performed by raising the patient’s leg to 30° to 70°. The result is positive if ipsilateral leg pain develops at less than 60°. A crossed SLR test raises the leg contralateral to the side of disk herniation. A positive crossed SLR test result is even more specific than a positive SLR test.[15][16]

The Stork test, which tests for spondylolysis, is another maneuver used clinically to investigate the cause of back pain. The examiner supports the patient while having them stand on one leg and hyperextending the back. The maneuver is repeated on the other side. The test result is positive if the patient experiences pain during hypertension.

The Adam test aids in evaluating for scoliosis. The patient bends over with the feet together, arms extended, and palms together. An examiner standing in front can appreciate a thoracic lump in patients with scoliosis.[17]

Testing the range of motion, limb strength, deep tendon reflex, and sensation helps assess the integrity of both the musculoskeletal and neurologic systems.

Red flags on history or physical exam warrant imaging and other diagnostic tests. Listed below are the signs to watch out for in each group: 

In adults:[18][19]

  • Malignancy:
    • History: History of metastatic cancer, unexplained weight loss
    • Physical exam: Focal tenderness to palpation in the setting of risk factors
  • Infection:
    • History: Spinal procedure within the last 12 months, intravenous drug use, immunosuppression, prior lumbar spine surgery
    • Physical exam: Fever, wound in the spinal region, localized pain, tenderness
  • Fracture:
    • History: Significant trauma (relative to age), prolonged corticosteroid use, osteoporosis, and age older than 70 years 
    • Physical exam: Contusions, abrasions, tenderness to palpation over spinous processes
  • Neurologic:
    • History: Progressive motor or sensory loss, new urinary retention or incontinence, new fecal incontinence
    • Physical exam: Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes

In pediatric patients:[20][21]

  • Malignancy:
    • History: Age younger than 4 years, nighttime pain 
    • Physical exam: Focal tenderness to palpation in the setting of risk factors
  • Infectious:
    • History: Age younger than 4 years, nighttime pain, history of tuberculosis exposure
    • Physical exam: Fever, wound in the spinal region, localized pain, and tenderness
  • Inflammatory:
    • History: Age younger than 4 years, morning stiffness lasting longer than 30 minutes, improving with activity or hot showers 
    • Physical exam: Limited range of motion, localized pain, and tenderness
  • Fracture:
    • History: Activities with repetitive lumbar hyperextension (as in sports activities like cheerleading, gymnastics, wrestling, and football)
    • Physical exam: Tenderness to palpation over spinous process, positive Stork test

Evaluation

History and physical examination are enough to determine the cause of back pain in most cases. Early imaging in the adult population correlates with worse outcomes, as it tends to result in more invasive treatments that provide little benefit to patients.[22][23] The same is true in the pediatric population. However, the presence of concerning signs warrants diagnostic testing. In adults, back pain persisting longer than 6 weeks despite appropriate conservative management is also an indication for imaging. In the pediatric population, the recommendation is to perform imaging tests for continuous pain lasting more than 4 weeks.[91]

Plain anteroposterior and lateral (APL) films of the axial skeleton can detect bone pathology (see Image. Multiple Myeloma Involving the Spine). Magnetic resonance imaging (MRI) is indicated for evaluating soft tissue lesions, such as the nerves, intervertebral disks, and tendons. Both imaging modalities can detect signs of malignancy and inflammation, but MRI is preferable when the soft tissues are involved.[24][25] Bone scans may show osteomyelitis, diskitis, and stress reactions but remain inferior to MRI in evaluating these conditions.[26]

Adolescents with MRI evidence of disk herniation need a computed tomogram (CT) to confirm or rule out apophyseal ring separation, which occurs in 5.7% of these patients.[27] 

Electromyography (EMG) or nerve conduction studies are indicated in patients with prior spinal surgery who may be experiencing radiculopathy or plexopathy as a complication. Image-guided diagnostic injection can help confirm sacroiliac joint injury.[92]

Laboratory tests may be necessary in some cases of back pain. Rheumatologic assays such as HLA-B27, antinuclear antibody (ANA), rheumatoid factor (RF), and Lyme antibodies are typically not helpful, being nonspecific for back pain.[28][29] However, the inflammatory markers C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be useful.[30] A complete blood count (CBC) and blood cultures may aid in diagnosing inflammatory, infectious, or malignant etiologies. High lactate dehydrogenase (LDH) and uric acid levels are commonly found in conditions associated with rapid marrow turnover like leukemia.[31]

Treatment / Management

Adult and pediatric back pain require different management approaches. Many cases have an unidentifiable cause, although degenerative disease and musculoskeletal injury are more common in adults than children. By comparison, overuse and muscle strain typically precipitate back pain in children and adolescents. Rare causes like malignancy and metabolic conditions also present differently in various age groups. Therefore, treatments must be appropriate for both the condition and the patient's age.

Management of Back Pain in Adults

For acute back pain in adults, serious conditions must first be ruled out. If there are no indications for further testing, the patient must be given reassurance about the condition and symptomatic relief. The first-line treatments are nonpharmacological and include the following:[93]

  • Early return to normal routines, except for heavy labor
  • Avoidance of activities that precipitate the pain
  • Patient education

Second-line options that may be offered to the patient include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, opioids, spinal manipulation, physical therapy, superficial heat application, and alternative treatments like acupuncture and massage. Education about the possible causes of back pain must be tailored to each patient's circumstances. Patient education is crucial in preventing back pain aggravation or recurrence. The patient may be advised to follow up after 2 weeks. Resumption of normal routines must be recommended if asymptomatic during follow-up.

For adult patients with acute radicular back pain, NSAID intake, exercise, traction, and spinal manipulation may be advised. Diazepam and systemic steroids have no added benefit. 

Diagnostics tests are necessary if serious conditions cannot be ruled out. Referral to other specialists for other tests and treatments must be considered.

The management approach to chronic back pain is similar. Start by ruling out serious conditions. If the cause is nonspecific, advise the patient to remain active and avoid precipitating factors. Exercise therapy and cognitive behavioral therapy are also considered first-line treatments.[32][33] Second-line treatments include spinal manipulation, massage, acupuncture, yoga, stress reduction, NSAIDs, selective norepinephrine reuptake inhibitors (SNRIs), and interdisciplinary rehabilitation.[34][35][36](A1)

The role of anticonvulsants like gabapentin and topiramate in managing back pain is uncertain.[37][38] Transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo in managing chronic back pain.[39](A1)

The American Pain Society recommends that surgical referral be reserved for patients with disabling low-back pain lasting longer than 1 year.[40] However, evidence is mixed for some of the most commonly performed invasive procedures, including epidural space injection therapy and lumbar disk replacement.[41][42](A1)

Management of Back Pain in Children and Adolescents

Pediatric back pain treatments are less widely studied. However, activity modification, physical therapy, and NSAIDs have broad support as first-line therapies. If serious pathology is present, the treatment is based on the standard of care for that condition. Spondylolysis resulting from repetitive spinal stress may be managed conservatively as in adults. However, some young patients actively engaged in sports may need a referral for surgical intervention.[43][44] Symptoms persisting beyond 6 months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation.[45][46](B2)

Patients with Scheuermann's kyphosis may be conservatively managed with physical therapy and guided exercise if the spinal curvature is less than 60°. Bracing may be added to these treatments for patients with curvature between 60° and 70°. Surgical correction is indicated for spinal curvature greater than 75°, especially if conservative measures have failed and the patient's skeleton is mature.[47][48] Spinal curvature of 20° or greater during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for a surgical referral.[49](B2)

Differential Diagnosis

Listed below are adult and pediatric conditions presenting with back pain. The associated symptoms and physical examination findings are also described. This list is not comprehensive, though it includes the most common or serious conditions producing this symptom.

Differential Diagnosis of Back Pain in Adults

  • Lumbosacral muscle strains and sprains: Usually from a traumatic incident or repetitive overuse; pain worsens with movement and gets better with rest; range of motion is restricted; muscles are tender to palpation
  • Lumbar spondylosis: The patient is typically older than 40 years; hip pain may be present; pain occurs with lower limb extension or rotation; neurologic exam is usually normal
  • Disk herniation: Usually involves the L4 to S1 segments; may have associated paresthesia, sensory change, loss of strength or reflexes, depending on the severity and nerve root involved
  • Spondylolysis and spondylolisthesis: Caused by repetitive spinal stress; may present with back pain radiating to the gluteal area and posterior thighs; neurologic deficits follow the L5 distribution.[50] 
  • Vertebral compression fracture: Localized back pain worsening with flexion; point tenderness on palpation; may be acute or chronic; steroid use, vitamin D deficiency, and osteoporosis are risk factors
  • Spinal stenosis: Accompanied by leg sensory and motor weakness relieved with rest (neurologic claudication); neurologic exam may be normal initially but progress with increasing stenosis
  • Tumor: May be accompanied by unexplained weight loss, focal tenderness to palpation, or malignancy risk factors on history (97% of spinal tumors are metastatic).[51] 
  • Infection: The patient may have a history of spinal surgery in the last 12 months, intravenous drug use, or immunosuppression; accompanying symptoms include fever, wound in the spinal region, localized pain, and tenderness, most commonly from vertebral osteomyelitis, diskitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess; consider tuberculosis if the patient comes from a developing country.[52] 
  • Fracture: May arise from trauma, prolonged corticosteroid use, and osteoporosis; common among patients older than 70 years; associated findings include contusions, abrasions, tenderness to palpation over spinous processes

Differential Diagnosis of Back Pain in Children and Adolescents

  • Tumor: May present with fever, malaise, weight loss, nighttime pain, and recent onset scoliosis; osteoid osteoma is the most common tumor presenting with back pain easily relieved by NSAIDs.[53][54][55]
  • Infection: Associated symptoms include fever, malaise, weight loss, nighttime pain, and recent-onset scoliosis; patients may refuse to walk; most common conditions are vertebral osteomyelitis, diskitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess; consider epidural abscess if neurologic deficits and radicular pain also appear.[56][57] 
  • Disk herniation and slipped apophysis: May present with acute back pain, radicular pain, and recent-onset scoliosis; physical findings include positive SLR test and pain on spinal forward flexion.
  • Spondylolysis, spondylolisthesis, and posterior arch lesion: Acute-onset back pain presents with radicular pain; hamstring tightness may be present; physical findings include positive SLR test and pain on spinal extension.
  • Vertebral fracture: Trauma is the most common cause; acute back pain may be associated with other injuries; neurologic deficits may be present on physical examination; stress fractures may present insidiously and produce progressive postural changes.
  • Muscle strain: Acute back pain is typically associated with muscle tenderness without radiation.Scheuermann’s kyphosis: Back pain is chronic and associated with rigid kyphosis.
  • Inflammatory spondyloarthropathies: Pertinent findings on history include chronic pain, morning stiffness lasting greater than 30 minutes, and sacroiliac joint tenderness.
  • Psychological disorder, eg, conversion and somatization disorder: Persistent subjective pain with normal physical findingsIdiopathic scoliosis: Most commonly asymptomatic, with a positive Adam test; back pain may be due to another cause.[58] 

Prognosis

In adults, the prognosis of back pain depends on the etiology. Most nonspecific cases resolve without serious sequelae. The success of conservative therapy and patient education in treating adult back pain shows that pain is subjective and often stress-related. For some patients with unidentifiable causes of back pain, prior back pain episodes, greater symptom intensity, depression, fear-avoidance behavior, and the presence of leg or widespread symptoms are associated with chronic, disabling back pain.[59]

Underlying social factors have significant prognostic accuracy.[60] Conditions such as low educational attainment, having a highly laborious job, poor compensation, and poor job satisfaction worsen outcomes, including disability rates.[61][62] Lifestyle activities also play a role. A body mass index (BMI) greater than 25 and smoking are associated with persistent back pain.[63].

Fewer studies have been made about back pain prognosis in pediatric patients than in adult individuals, though it appears the etiology also impacts outcomes.[64] For example, back pain caused by cancer is more likely to cause disability than muscle strain.[65] Some studies show that nonspecific back pain in younger people worsens with behavioral comorbidities.[66] Conduct problems, attention deficit hyperactivity disorder (ADHD), passive coping, and fear-avoidance behavior have been implicated in the literature as having a negative impact on back pain.[67][68]

Complications

The underlying back pain etiology determines the potential for complications. The condition can have both physical and social consequences. Physically, back pain can become chronic and associated with deformity, neurologic deficits, or both. Socially, the complications of this condition include disability, decreased gross domestic product, and increased absenteeism. A 2015 study found that back pain has caused 60.1 million years of disability worldwide, making this symptom the most common cause of disability globally.[69] In the US, low-back pain is the most common reason for disability.[70]

Addressing the problem before it becomes chronic helps prevent complications. Early ambulation helps improve outcomes, while sedentariness leading to obesity tends to worsen the prognosis.

Postoperative and Rehabilitation Care

The underlying cause, patient comorbidities, and health goals determine back pain rehabilitation efforts. The McKenzie method is often cited as beneficial for nonspecific low-back pain treatment, especially if it is chronic.[71] The Clinical Practice Guidelines for Physical Therapy recommend manual therapy, trunk strengthening, centralization, directional preference, and progressive endurance exercises for rehabilitation. Occupational therapy can also help patients manage activities of daily living and use adaptive equipment as needed. Using assistive devices during patient transfers reduces low-back pain incidence in female healthcare workers.[72][73]

Deterrence and Patient Education

Patient education about preventing back pain recurrence or aggravation must be tailored to personal factors. For example, individuals with jobs that do not require hard physical labor must be reminded to stay active to maintain a healthy body weight. A BMI greater than 25 correlates with worse outcomes. The same reminder must be given to people with labor-intensive occupations. However, these individuals should also avoid factors precipitating back pain, such as heavy-load lifting and excessive or repeated back-twisting. These patients should lighten their loads or use lifting equipment when moving weighty objects.

All patients must be reminded to avoid smoking, which increases the risk of back pain in people of any age.[74][75] Intensive patient education lasting for 2.5 hours discussing activity modification, staying active, and early return to normal activity has been proven effective in encouraging adult patients to return to work.[76]

In pediatric patients, evidence is mixed about whether bookbag weight plays a role in pediatric back pain. Still, the American Academy of Pediatrics recommends that bookbags do not exceed 10% to 20% of a child’s body weight.[77]

The vast majority of back pain cases are self-limited. However, all discharged patients advised to follow up should be instructed to seek medical attention immediately for concerning signs like sudden sensory and motor weakness.

Pearls and Other Issues

The following are the practice pearls worth remembering in back pain management:

For Adults

  • History and physical examination usually suffice for evaluating atraumatic, acute back pain without clinical red flags. Wait 6 weeks for symptom resolution before ordering imaging tests.[78][79]
  • Patient education focusing on remaining active is the first-line treatment for nonspecific back pain. Studies show that pharmacologic and physical therapy do not consistently benefit patients with back pain. However, clinicians may consider NSAIDs, opioids, and SNRIs like duloxetine as second-line therapy for nonspecific chronic low-back pain. These medications are more effective than placebo for this condition.[80][81]
  • Acetaminophen, antidepressants (except SNRIs), lidocaine patches, and TENS are not consistently more effective than placebo in treating chronic low-back pain.[82][83]
  • Consider a physical therapy referral for the McKenzie technique to reduce recurrence risk.[84][85]

For Children

  • Children with transient back pain and a history of minor injury but without significant physical findings can be treated conservatively without further evaluation.
  • Abnormal physical findings, constant pain, nighttime pain, or radicular pain are indications for further evaluation.[86]
  • Plain APL films are recommended as the first-line radiographic studies.
  • Consider laboratory tests in the presence of clinical red flags. Thoracic malignancy and infection are more likely in children than adults, especially those younger than 4 years.[87]

Enhancing Healthcare Team Outcomes

Integrating the expertise of various healthcare professionals ensures comprehensive care, better outcomes, and improved quality of life for individuals experiencing back pain. The multidisciplinary team for managing back pain comprises the primary care provider, nurse, pharmacist, nutritionist, physical therapist, occupational therapist, radiologist, and medical specialists appropriate to each case. 

The primary care provider is the first medical specialist who examines the patient. Evaluation of back pain starts with a complete medical history and physical examination. From there, the primary care provider determines the appropriate initial treatment and evaluates the need for further diagnostic testing and specialist referral. The primary care provider also takes charge of patient education and communicating follow-up recommendations to the patient. When educating patients, smoking cessation and maintaining a healthy body weight should be emphasized.[88]

The nurse should reiterate the important parts of patient education and follow-up instructions. Evidence-based answers must be given to patients asking about the role of nonpharmacologic therapy and continued physical activity in back pain management. The nurse must ensure the patient is clinically stable before discharge and care plans are coordinated before the next appointment.

If the primary care physician prescribes medications, the pharmacist can help educate patients about the prescribed drugs' back pain-specific benefits and risks. Intake instructions and the potential risks of overdose must be emphasized. The pharmacist should not hesitate to contact the primary care provider to clarify a patient's prescription.

Obesity in a patient with back pain is associated with adverse outcomes. Patients can work with nutritionists to make healthier dietary choices and maintain a healthy weight. If a patient is obese, an obesity medicine specialist can prescribe antiobesity medications as adjunct to lifestyle modifications to help them lose significant weight.

The physical therapist can prescribe the appropriate strength and endurance exercises for managing back pain and preventing recurrences. Physical therapy is effective in weaning patients with back pain from opioid use.[89] An occupational therapist can provide ergonomic guidance and recommend assistive devices to manage back pain in work and home settings.

The radiologist helps the primary care physician interpret imaging findings. These specialists can also make recommendations for additional imaging tests if necessary.

The primary care physician can make referrals to other specialists as needed. A pain specialist can help patients with chronic back pain by modifying their current pharmacologic treatment regimen or performing a pain-management procedure. A rheumatologist may be consulted for back pain associated with signs of chronic inflammatory disease. Severe radiculopathy or rapid neurological changes are indications for prompt neurosurgery referral. A mental health therapist can teach stress-coping techniques, administer cognitive behavioral therapy, and prescribe other treatments appropriate for back pain with a prominent psychological component.[90] Alternative medicine providers may also be instrumental in improving patient function.

The interprofessional team should communicate with each other to prevent duplicating diagnostic tests and contradicting treatments, both of which can hinder a patient's progress.

Media


(Click Image to Enlarge)
<p>Multiple Myeloma Involving the Spine

Multiple Myeloma Involving the Spine. This lateral lumbar spine x-ray shows lytic lesions in the L1 and L4 vertebral bodies.

Contributed by Steve Lange, MD

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