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Lower Back Pain

Acute lower back pain is very common, affecting 80% of adults at some time during their life. It is one of the top 5 reasons why adult patients visit their physicians' offices. In the United States, lower back pain has an annual cost of approximately $50 billion related to medical care and disability. Disability due to back pain has steadily increased despite the development of a postindustrial economy and advances in medical care. The good news is that 70-80% of those affected recover in six weeks regardless of the method of treatment. Recurrences, however, are common and affect 40-80% of patients.

The fact that the underlying causes of back pain are incompletely understood may be limiting advances in back pain care. Although the mechanical compression of nerves is an important factor, other mechanisms also appear to be involved in the etiology of back pain. These mechanisms include the local release of chemical irritants from the intervertebral disks, an autoimmune reaction to exposed disk material, and increased lactic acid concentrations or lower pH levels in the environment surrounding the nerve roots.

As stated above, acute back pain is common and costly. In addition, the appropriate treatment of lower back pain is controversial. Consequently, the Agency for Health Care Policy and Research (AHCPR) convened a 23-member multidisciplinary panel to develop guidelines for the evaluation and treatment of acute lower back problems in adults. Back problems included activity intolerance due to low back pain and back-related lower extremity symptoms that were less than three months in duration. These guidelines were intended to assist primary care physicians in the detection of serious spinal disease in the patients.

In the initial assessment of a patient with acute lower back symptoms, the evaluating physician should obtain a focused history and perform a physical examination, including neurological screening. Certain suspicious information about the patient should be sought. These worrisome facts or red flags include the following:

Trauma
Corticosteroid use
Age greater than 50 years, which makes the patient susceptible for vertebral compression fractures
History of cancer
Unexplained weight loss
Failure of conservative therapy or rest to relieve pain, which suggests cancer involving the spine
History of intravenous drug abuse, urinary tract infection, skin infection, or persistent fever, which suggests spinal osteomyelitis (infection of the bone and disks of the spine)

If no red flags are present, then further diagnostic tests are not thought to be helpful, and a trial of rest and medical management with anti-inflammatory and pain medications is usually prescribed.

If red flags are found in the initial assessment of a patient with acute lower back pain, further diagnostic testing may be helpful.

If a vertebral compression fracture is suspected, lumbar spine X-rays are an effective way to diagnose or exclude this condition. If no fracture is seen on X-rays, but is still suspected after 10 days, a nuclear medicine bone scan or a consultation with a neurosurgeon or orthopedic surgeon is the next step.

If either cancer or infection is suspected on the basis of the patient's history, blood and/or urine laboratory tests are performed. If these tests are suggestive of either cancer or infection, clinical consultation and bone scan or X-rays should be obtained.

Magnetic resonance imaging (MRI) can further define any abnormality seen on bone scans or X-rays.

If a patient has acute lower back pain and signs of spinal cord compression (e.g., bowel and bladder incontinence, severe leg weakness or paralysis) or with a rapidly progressive neurological deficit, emergency clinical consultation and an emergency imaging study, usually MRI, is performed so that definitive care can be administered.

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