Outpatient / MSK
Back Pain
# *** [Acute/Chronic] Back Pain 2/2 ***
Intake:
- Onset/Trigger: *** trauma, accident, fall, lifting, activity
- Location: ***
- Timing: *** constant, AM stiffness, worse at the end of the day, wake from sleep
- Radiation: *** down back/side of leg
- Severity: ***
- Quality: ***
- Worsen/Improve: ***
- Associated Symptoms: ***
- Impact on Function: ***
- Medications Trialed: *** NSAIDs, tylenol, cyclobenzaprine, lidocaine patch, duloxetine
- Alternative Therapies Trialed: *** heat/ice, stretching, massage, acupuncture, yoga
- Pertinent Imaging: *** Xray, MRI
- Exam Findings: *** palpate spine, step-off, range of motion, LE strength/sensation/reflexes, straight leg raise
- Red Flags: *** focal neuro deficits including cauda equina (weakness, urinary/bowel retention/incontinence, saddle anesthesia), fever, trauma, c/f fracture, h/o cancer, infection, immunocompromised, weight loss, IVDU, long-term steroid use, recent spinal surgery, worse at night
- Can't Miss: cauda equina, spinal infection, aortic aneurym/rupture, malignancy
DDx:
MSK - lumbar strain, muscle spasm, degenerative disc or facet, herniated disc, sciatica, spinal stenosis, spondylolisthesis, compression fracture, rib fracture
Neoplastic - spinal mets, primary tumor, intraabdominal malignancy
Infectious - osteomyelitis, spinal epidural abscess, psoas abscess, pyelo, cholecystitis/cholangitis
Vascular - hematoma, infarction, aortic aneurysm/dissection/rupture, RP hematoma
Inflammatory - ankylosing spondylitis, reactive arthrtitis
Other- pancreatitis, nephrolithiasis, PUD
Plan:
- Lifestyle: *** exercise, posture, weight loss, quit smoking
- Medications: *** (NSAIDs 2-4 weeks - ibuprofen 600-800 q4-6, naproxen 250-500 BID; topical vs oral muscle relaxants - cyclobenzaprine 5-10mg PO TID max 2-3 weeks, tizanidine 4mg TID; lidocaine patches; duloxetine for chronic pain; rarely opioids in extreme cases)
- Physical Therapy: ***
- Other Therapies: *** heat/ice packs, massage, acupuncture, yoga, CBT, mindfulness
- Labs: *** if c/f infection - CBC, ESR, CRP; if c/f fracture - calcium, VitD; if c/f inflammatory - HLA-B27
- Imaging: *** non-con MRI or Xray after conservative management for at least 4-6 weeks unless red flags including focal neuro deficits, cauda equina (weakness, urinary retention/incontinence, saddle anesthesia), trauma, c/f fracture, cancer, infection
- Refer: not improving after 6-8 weeks, for epidural injections; concerning imaging for compression, severe or progressive neurological deficits
Template coming soon
Patient Guidance and Information
Acute Back Pain
Based on your history and physical exam, we believe that your back pain is likely due to ***.
Most acute back pain resolved within 4-6 weeks with supportive care.
While your body heals, we recommend continuing activity as able, and treating with *** (NSAID, muscle relaxant). Other things that can help with pain include heat/ice packs, stretches, and massage.
Some stretches can be found at this link: https://www.healthline.com/health/lower-back-stretches
You *** [do/do not] currently need to have any labs or imaging done.
Please let us know how you are doing in 2-3 weeks. If things are not improving, we may trial other medications, or consider a consult to physical therapy.
If You Remember Nothing Else
Acute back pain in the outpatient setting is most commonly due to MSK etiologies and often resolves within 4-6 weeks with supportive care. Prioritize NSAIDs and muscle relaxants along with other modalities like heat/ice, massage, and stretching. Physical therapy has been validated in sciatica, but not other etiologies of back pain. Labs and imaging should only be pursued if there are red flags including focal neuro deficits, infection, cancer, immunocompromise, weight loss, IVDU, or long-term steroid use. Otherwise, imaging can be pursued after 4-6 weeks and should start with an X-Ray followed by a lumbar MRI. Many findings of degeneration are not actually linked to the pain the patient is experiencing. Make sure the pain is not actually flank or abdominal pain.
Clinical Pearls
- 75-90% of presentations for back pain improve over 4 weeks
- Muscle spasms will present with acute unilateral tenderness
- Spinal stenosis improves when leaning forward or walking downhill
- Inflammatory pain is present at rest or night and gets better with activity and leads to limited ROM; most commonly starts age 20-40
- Imaging should be deferred unless there are red flags because herniation, disc bulging, and DJD are common findings but do not necessarily cause the back pain
- You do not need to image for isolated radiculopathy (i.e sciatica pain) unless there is a focal deficit
- 90% of disc herniation compresses L4-S1
- Physical Therapy and exercise have been shown to benefit in sciatica pain, but value is not as clear in other causes of back pain
- Levels for Strength Exam - L2: hip flexion; L3: knee extension; L4: dorsiflexion; L5: great toe flexion; S1: plantarflexion
- Unproven medications in back pain - tylenol, gabapentin/pregabalin, prednisone, lidocaine patches
- It’s important to educate patients - namely that most acute pain does improve over 4-6 weeks, but that complete pain relief is unlikely; rather the goal is to figure out lifestyle modifications and methods to make the pain tolerable over the long-term
Trials and Literature
- Meta-Analysis of Anticonvulsants for Low Back Pain - punchline - they likely do not work
- Meta-Analysis of NSAIDs for Acute Low Back Pain - NNT for pain relief is ~14
- Meta-Analysis of MRI for Chronic Back Pain - showed no overall benefit
- LESS Trial - Epidural Injection for lumbar spinal stenosis does improve disability scores and pain at 6 weeks
- SPACE Trial - opioids not superior to non-opioids in improving function over 12 months
- PT works for acute back pain with Sciatica
- Pregabalin does not seem to work in acute and chronic sciatica
- 70-90% of patients improve within 4 weeks
Other Resources
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