Review Article

Low Back Pain

Address correspondence to
Dr Jinny O. Tavee, Cleveland
Clinic, Department of
Neurology, S-90, 9500 Euclid
Jinny O. Tavee, MD; Kerry H. Levin, MD, FAAN Ave, Cleveland, OH 44195,
taveej2@ccf.org.
Relationship Disclosure:
Dr Tavee has received
ABSTRACT personal compensation for
Purpose of Review: This article provides an overview of evaluating and treating low lectures from Mallinckrodt
Pharmaceuticals and has
back pain in the outpatient setting. received grant/research
Recent Findings: As most cases of acute low back pain have a favorable prognosis, support for work in clinical
current guidelines on imaging studies recommend conservative treatment for 6 weeks trials from Araim
Pharmaceuticals, Inc and
prior to obtaining an MRI if no red flags are present. Of these red flags, a prior history Mallinckrodt Pharmaceuticals.
of cancer is the strongest risk factor for a malignant etiology and requires urgent Dr Levin receives personal
evaluation with MRI. Management of acute low back pain is mainly conservative with compensation for serving as
director of the American
oral non-narcotic analgesics and mobilization as the initial recommendations. For Board of Psychiatry and
patients with radiculopathy, epidural steroids may result in short-term pain relief, but Neurology, serves on the
long-term effects are still unclear. editorial boards of
Continuum and Muscle &
Summary: A systematic, evidence-based approach to the patient with low back pain is Nerve, and receives publishing
key to providing safe and cost-efficient care. royalties from Elsevier and
UpToDate, Inc.
Unlabeled Use of
Continuum (Minneap Minn) 2017;23(2):467–486.
Products/Investigational
Use Disclosure:
Drs Tavee and Levin report
no disclosures.
INTRODUCTION EPIDEMIOLOGY * 2017 American Academy
of Neurology.
Low back pain is the third most common More than 25% of adults in the United
disorder presenting in the neurology States report having experienced low
outpatient clinic (behind peripheral back pain within the preceding 3 months,
neuropathy and migraine, respectively) with a peak prevalence occurring in
and accounts for more than 1 million adults aged 45 to 64 years, and a lifetime
office visits each year.1 While most prevalence of up to 84%.2Y4 Women are
patients initially present to their primary slightly more affected than men and
care physician, early neurologic evalua- also report a higher rate of recurrence.2,3
tion may help guide the patient toward Radicular involvement (reported as sci-
the appropriate level of diagnostic test- atica) is less common, with an estimated
ing and treatment, especially in the prevalence of 1.2% to 43%.5 Risk factors
presence of nerve root involvement. for back pain include obesity, increas-
Low back pain is usually defined as ing age, heavy manual work (twisting,
acute when onset is less than 4 weeks, heavy lifting, vibration), smoking, psy-
subacute if symptoms are present for 4 chosocial factors (depression, stress),
to 12 weeks, and chronic when symp- and deconditioning.6
toms persist for more than 12 weeks. The socioeconomic burden of low
Most cases are localized to the spine back pain is a significant problem
and paraspinal region with no neuro- worldwide. In a recent global survey,
logic symptoms and are considered low back pain was found to be the
musculoskeletal or non-neurologic. In number one cause of disability.7 In the
contrast, neurologic low back pain is United States alone, the direct cost is
accompanied by radicular symptoms, estimated at $34 billion annually, al-
which include leg weakness, radiating though when lost wages and other
pain, or sensory changes that correlate indirect costs are included, this figure
with the affected nerve roots. exceeds $100 billion.2,8

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 Low Back Pain

KEY POINTS
h The number one cause
of disability worldwide is
low back pain.
h Disk herniation is the
cause of radiculopathy
in 90% of patients
under the age of 65.
PATHOPHYSIOLOGY
While musculoskeletal and neurologic
low back pain may share similar contrib-
uting factors, the presence (or absence)
of nerve root involvement results in
two distinct pathophysiologic entities.
Musculoskeletal Low Back Pain
The source of musculoskeletal (non-
neurologic) back pain is often non-
specific and difficult to identify in most
patients. Possible mechanisms include
degenerative spine changes and injury
to local spinal structures, which include
the vertebral column, ligaments, and
surrounding muscles and soft tissues.
Heavy lifting and other activities that
lead to increased tension may result in
muscle fiber or tendon disruption. Re-
petitive motions or overuse of the para-
spinal muscles, especially those that are
deconditioned or inactive at baseline,
may cause pain and spasms due to
metabolic hyperactivity and production
of lactic acid.9 Arthropathy of the sa-
croiliac and facet joints may also con-
tribute to the formation of low back pain.
Neurologic Low Back Pain
In 90% of patients under the age of 65
with radicular (neurologic) pain, the
pain is a result of nerve root compres-
sion caused by disk herniation.10 The
disk itself has no nociceptive fibers
and does not result in pain until the
herniated portion comes into contact
with either the dural lining of the
spinal nerve root sleeve or the poste-
rior longitudinal ligament.9 In older
patients, the nerve root is often affected
by other age-related degenerative spine
changes, which include ligamentous hy-
pertrophy, osteophyte formation, facet
joint arthropathy, and neural foraminal
narrowing, although disk herniation
may also play a role (Figure 6-1). Nerve
root compression results in focal ische-
mia, which may affect axon transport,
and edema.9 Local inflammation may
also occur due to an immunogenic
response to the exposed contents of
the nucleus pulposus.9 This, in combi-
nation with the structural changes
caused by compression, can result in
more severe radicular pain.

FIGURE 6-1 Anatomy of degenerative lumbar spine disease. Nerve

root compression may be caused by a number of
degenerative changes that result in neural foraminal
narrowing or direct nerve impingement.

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Lumbar Spinal Stenosis
In addition to narrowing of the neural
foramina, degenerative spine changes
may result in central canal stenosis and
compression of spinal nerve roots via
direct impingement, CSF flow obstruc-
tion, or vascular compromise.11 A prior
history of local trauma and surgery are
other factors that can contribute to
spinal stenosis, whereas congenital
spine abnormalities are the primary
etiology in younger patients. Lumbar
spinal stenosis is a slowly progressive
degenerative condition that is the most
common reason for spinal surgery in
older patients.12
CLINICAL HISTORY
The clinical evaluation of low back pain
begins with a focused history that
should address three main points: (1)
pain description (duration, location,
severity, triggers, and relieving factors),
(2) determination of neurologic in-
volvement, and (3) identification of
red flags that may indicate the presence
of serious spinal pathology or systemic
disease requiring urgent intervention.
Duration
Establishing the duration (acute ver-
sus chronic) of pain helps to provide a
framework by which further evaluation
and treatment may be determined. Most
patients with acute musculoskeletal low
back pain will experience spontaneous
improvement within 2 to 4 weeks,
while symptoms of acute radicular
pain follow a more protracted course
(up to 6 to 8 weeks) but also tend
to be self-limited. Aggressive diagnostic
testing is typically not necessary for
either case in the absence of red flags
or severe neurologic deficits. Patients
presenting with chronic low back pain
also do not usually require extensive
evaluation but should be questioned
about any recent symptoms sugges-
tive of a new, superimposed disorder.
Continuum (Minneap Minn) 2017;23(2):467–486
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KEY POINTS
Location h Lumbar spinal stenosis is
Musculoskeletal low back pain is often a slowly progressive
described as a deep ache that is poorly degenerative condition
localized, although some patients will that is the most
report that the pain is mainly in the common reason for
center of the lower back. Radicular spinal surgery in
disease is a sharp, burning, or needle- older patients.
like pain that radiates down into one or h The clinical evaluation
both legs in a dermatomal distribution of low back pain should
(Table 6-1). address three main
points: (1) pain
Severity description (duration,
location, severity,
Pain severity should be routinely asked
triggers, and relieving
about as part of the history but is widely
factors), (2) neurologic
variable depending on psychosocial, involvement, and
cultural, and other factors. (3) identification of
red flags.
Triggers/Relieving Factors
h Low back pain that
Exacerbating and relieving factors, par- persists in all positions
ticularly positional changes, are an is concerning for
integral portion of the history. For most malignancy or infection
patients with either musculoskeletal or and should prompt
neurologic low back pain, symptoms further diagnostic
are reported to be worse with sitting (es- workup.
pecially with prolonged driving or plane
travel) and improved when standing for
a short period of time or lying supine. In
patients with musculoskeletal pain due
to facet joint disease, osteoarthritis, or
muscle strain, the reverse may be true,
with pain reported as worse with stand-
ing and relieved with sitting.13Y14 Spinal
stenosis is also worse with standing as
well as walking. Sacroiliac joint disease
may be exacerbated by transitioning
between sitting and standing.15 Low
back pain that persists in all positions
is concerning for malignancy or infec-
tion and should prompt further diag-
nostic workup. Patients with low back
pain due to ankylosing spondylitis may
also fail to feel improvement while in
the supine position.
Neurologic Involvement
In addition to symptoms of radicular
pain, patients with neurologic involve-
ment may report weakness of one or
both legs described as difficulty with
ContinuumJournal.com 469
 Low Back Pain

a
TABLE 6-1 Clinical Presentation in Patients With Lumbar Radiculopathy

Root Dermatomal Sensory

Level Pain Distribution Distribution Weakness Reflex Abnormality
L1 Inguinal region Inguinal region Hip flexion Cremasteric reflex
L2 Inguinal region, Anterior thigh Hip flexion, hip Cremasteric reflex,
anterior thigh adduction thigh adductor reflex
L3 Anterior thigh, knee Distal anteromedial Knee extension, hip Patellar reflex, thigh
thigh including knee flexion, hip adduction adductor reflex
L4 Anterior thigh, Medial leg Knee extension, hip Patellar reflex
medial aspect leg flexion, hip adduction
L5 Posterolateral thigh, Lateral leg, dorsal Foot dorsiflexion, knee Not applicable
lateral leg, medial foot foot, and great toe flexion, hip abduction
S1 Posterior thigh and Posterolateral leg, Foot plantar flexion, knee Achilles reflex
leg, lateral foot lateral aspect of foot, flexion, hip extension
sole of foot
a
Modified with permission from Levin KH, Continuum (Minneap Minn).9 B 2001 American Academy of Neurology. journals.lww.com/
continuum/Citation/2001/07010/LOW_BACK_AND_NECK_PAIN_.2.aspx.

ascending and descending stairs, epi-
sodes of the leg or legs giving way while
standing, or slapping of the foot while
walking, which typically indicates a
footdrop and L5 nerve root involvement.
Sensory changes may be reported as
numbness, tingling, cold sensations,
electric shocks, or severe burning pains.
Other sensations that may be reported
include the feeling of water running
down the leg or a “pop” in the lower
back at onset followed by the gradual
development of radicular symptoms.13
Radicular pain is usually worsened by
factors that increase intrathoracic pres-
sure (eg, coughing, sneezing, or the
Valsalva maneuver).
Neurogenic claudication, also known
as pseudoclaudication, commonly oc-
curs in lumbar spinal stenosis and is
characterized by pain, cramps, or weak-
ness that radiates down one or both
lower extremities. Symptoms worsen
with walking or standing and are imme-
diately relieved with rest or flexion of
the spine forward, which results in
enlargement of the spinal canal and
foramina as well as increased space for
the compressed nerve roots. Patients
often report improved pain with bend-
ing over on the commode or leaning
forward against a shopping cart, a well-
known phenomenon referred to as the
grocery cart sign.
Red Flags
Although serious spinal pathology is
rare in the primary care setting (less
than 1%), the identification of red flags
for disorders such as cauda equina
compression, cancer, and vertebral in-
fection remains key in the evaluation of
patients with low back pain (Table 6-2).16
Neurologic red flags include bowel/
bladder changes and severe or rapidly
progressive sensory or motor deficits. A
history of bilateral asymmetric leg
weakness in the presence of urinary
retention is especially concerning for
cauda equina involvement, which re-
quires urgent imaging studies and
surgical evaluation.
Recent systematic reviews found
that a prior history of cancer had the

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TABLE 6-2 Red Flags in the
Evaluation of Acute
Low Back Pain
b Neurologic
Red flags for cauda equina
compression
Bowel/bladder disturbances
Saddle anesthesia
Bilateral asymmetric deficits
Red flags for severe neurologic
involvement
Rapidly progressive deficits
Multilevel or bilateral
involvement
Prominent motor weakness
(eg, footdrop or hip flexion
weakness)
b Non-neurologic
Red flags for cancer
Prior history of cancer
Unexplained weight loss
Pain in supine position
More than 50 years of age
Pain duration longer than
1 month
Red flags for spinal fracture
Chronic corticosteroid use
More than 70 years of age
Trauma
Red flags for spinal infection
Fever
Recent infection
IV drug use
IV = intravenous.
highest predictive value for detection
of malignancy even in the absence of
other red flags.16,17 Other risk factors
for cancer include failure to improve
after 1 month, pain that is present in
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KEY POINTS
all positions, and unexplained weight h A prior history of cancer
loss. Epidural abscess and other verte- has the highest
bral infections should be suspected in predictive value for
the setting of fever, recent infection, detection of malignancy
or IV drug use, although patients who even in the absence of
are diabetic or otherwise immuno- other red flags.
compromised may present without h Compression fractures
fever. Compression fractures are asso- are associated with
ciated with older age, acute trauma, older age, acute trauma,
and chronic steroid use. Of note, the and chronic steroid use.
determination to proceed with further
testing should be based on the pres-
ence of a combination of positive red
flags and clinical judgment due to low
predictive values of individual risk
factors (with the exception of prior
cancer history) (Case 6<1).16,17
A careful history is also important to
evaluate for an underlying systemic
disorder that may present with low back
pain. Questions regarding abdominal
and urinary tract symptoms should be
posed since intraabdominal/pelvic pa-
thology may present with referred pain
to the back. Diffusely reduced mobility
of the neck and back may be sugges-
tive of an inflammatory spondylo-
arthropathy. Other questions to ask
include whether or not the patient
has a prior history of back pain as this
is the strongest risk factor for an acute
episode.18 Along these lines, infor-
mation on previous imaging study
findings and treatments tried should
be obtained. A history of more re-
mote trauma or recent strenuous
physical activity may also be impor-
tant. While this may not establish the
specific source of the pain, it may
point toward a mechanical cause
rather than an underlying systemic
disorder (eg, malignancy), although
some patients will not recall an
inciting event and report that they
simply woke up with the symptoms.
Information regarding psychosocial
factors, worker’s compensation claims,
and substance abuse may also be help-
ful in predicting evolution to chronic
ContinuumJournal.com 471
 Low Back Pain

Case 6<1
A 57-year-old woman who was previously healthy presented with a 4-month history of intermittent low
back pain that had become worse over the last 2 weeks. Prior to onset, the patient had carried a suitcase
down the stairs and later that day had developed severe right-sided lower back pain that self-resolved
after 2 weeks. The pain recurred 2 months later after the patient again lifted something heavy, but these
symptoms also improved. Then 2 weeks before presentation, the severe pain returned, accompanied by
new burning paresthesia down the right buttock and posterior thigh as well as progressive difficulty
walking. The pain was much worse than before and
was not relieved by ibuprofen or any positional changes.
In fact, she had been unable to sleep well for the
last 2 weeks because of pain while lying down at night.
She denied any trauma or preceding illnesses.
Examination showed right-sided gastrocnemius
weakness and a reduced right ankle deep tendon reflex.
Lumbar MRI without gadolinium demonstrated
compression fracture deformities of the T12 and L5
vertebral bodies with diffusely abnormal signal
throughout the spine and bilateral sacrum (Figure 6-2).
Further evaluation revealed evidence of multiple
myeloma with a small soft tissue mass extending into
the S1 neural foramina on the right, resulting in nerve
root impingement. The patient underwent extensive
chemotherapy with aggressive pain management and
was in remission 2 years later.
Comment. Although the first two episodes of low
back pain may have been triggered by heavy lifting and
appeared musculoskeletal in nature, the third episode
was radicular and accompanied by red flags that
included pain present in all positions and progressive
neurologic deficits. Furthermore, the neurologic
examination was consistent with a right-sided S1
radiculopathy with significant motor weakness. Early
MRI was thus warranted and revealed changes FIGURE 6-2 Imaging of the patient in Case 6-1.
Sagittal short tau inversion recovery
consistent with malignancy. Disease-appropriate (STIR) MRI demonstrates compression
therapy was initiated with resultant stabilization of fracture deformities of the T12 and L5 vertebral
the patient. bodies (solid arrows) with diffusely abnormal signal
throughout the spinous processes (dashed arrows).

low back pain that may be refractory to
multiple treatment modalities.
PHYSICAL EXAMINATION
In conjunction with the history, a
careful neurologic examination can help
establish the presence of radicular dis-
ease and localize the lesion (Table 6-1).
With neurologic involvement, sensory
loss or hyperesthesia to pinprick and
light touch may occur within a specific
dermatome. Similarly, patients may
demonstrate a myotomal pattern of
weakness, although the motor exami-
nation is often confounded by guarding
or giveway weakness due to pain.
Despite these limitations, every effort
should be made to test the strength of
individual muscles within L2 to S1 myo-
tomes, particularly those innervated
by the L5 and S1 nerve roots as these
levels are affected in 95% of lumbar-disk

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herniations.12,19 Strength testing of
ankle dorsiflexion (L5), great toe exten-
sion (L5 to S1), knee flexion (L5 to S1),
hip flexion (L2 to L4), and knee exten-
sion (L2 to L4) constitutes a basic motor
examination. Evaluation of deep tendon
reflexes, which are unaffected by pain
and patient effort, is also important as
the asymmetric absence of a knee (L2
to L4) or ankle reflex (S1) may serve as
the only objective neurologic finding on
an otherwise normal examination.
However, deep tendon reflexes may
be absent in patients older than the
age of 60 (absent ankle jerks) and in
patients with prior back surgery or knee
replacement. Patients with reported
bowel/bladder dysfunction should be
assessed for rectal tone, anal wink
reflex, and saddle anesthesia to evalu-
ate for cauda equina dysfunction.
Valuable information can also be
obtained from the gait examination. As
described previously, patients with lum-
bar spinal stenosis may demonstrate
forward flexion of the trunk while
walking (grocery cart sign) to increase
the diameter of the spinal canal and
relieve compression. A Trendelenburg
gait may be seen in patients with hip
abduction weakness due to L5 nerve
root compression or primary hip pa-
thology. Because of the weakened
pelvic muscles on the affected side,
the patient overcompensates by placing
more weight on the contralateral leg
while taking a step forward with the
affected one, resulting in a lowered
hip on the unaffected side while
walking. Stressed gait testing, in which
patients are asked to walk on their
toes and heels, may be more sensitive
than direct manual testing of ankle
plantar flexion and dorsiflexion. The
inability to walk on the toes points
toward gastrocnemius (S1) weakness,
whereas difficulty heel walking may
indicate footdrop and tibialis anterior
(L5) weakness.
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KEY POINTS
The neurologic examination may be h Patients with reported
further augmented by specific maneu- bowel/bladder
vers that can help detect the presence dysfunction should be
of radicular disease and are easily assessed for rectal tone,
performed at the bedside. anal wink reflex, and
saddle anesthesia to
Straight LegYRaising Test evaluate for cauda
The straight legYraising test is carried equina compression.
out with the patient in the supine h Patients with lumbar
position while the examiner raises the spinal stenosis may flex
leg on the affected side with the knee forward at the trunk
extended (Figure 6-3). The test is pos- while walking (grocery
itive and suggestive of L5 or S1 nerve cart sign) to increase the
root compression if radicular symptoms diameter of the spinal
canal and relieve nerve
are reproduced or worsened when the
root compression.
leg reaches an angle between 30 de-
grees and 70 degrees. An increase in
symptoms at less than 30 degrees may
be nonphysiologic, while pain present
at greater than 70 degrees may occur in
normal individuals and is unlikely to be
clinically relevant. This test may also be
performed with the patient sitting. Pain
present only when the patient is su-
pine, but not when sitting up (with leg
raised), suggests a nonorganic etiology.20
Crossed Straight-Leg Raising Test
During the crossed straight-leg raising
test, pain is reproduced when the con-
tralateral or unaffected leg is raised with
the knee extended. This is a more
specific test for disk herniation than
the ipsilateral straight legYraising test,
but is not as sensitive.
Bragard Sign
The Bragard sign is another variation of
the straight legYraising test in which the
examiner dorsiflexes the patient’s foot
at the point when the patient begins
to experience pain as the leg is being
raised (Figure 6-4). This further in-
creases the nerve root tension and re-
sults in worsening pain.
Femoral Stretch Test
The femoral stretch test is carried out
with the patient in a prone position while
ContinuumJournal.com 473
 Low Back Pain

FIGURE 6-3 Straight legYraising test. With the patient in the

supine position, the examiner raises the leg on
the affected side with the knee extended.
The test is positive if radicular symptoms are reproduced or
worsened when the leg reaches an angle between 30 degrees
and 70 degrees.

the affected leg is gently lifted off the
table and then flexed at the knee
(Figure 6-5). Pain in the anterior thigh
may indicate L2 to L4 root compression.
Patrick Test
The Patrick test (also known as the
flexion, abduction, external rotation
[FABER] test) is carried out while the
patient is supine and the lateral ankle of
the affected leg is placed on the contra-
lateral knee. The affected knee is then
slowly brought down to the examina-
tion table (Figure 6-6). Pain during this
maneuver is suggestive of pathology in
the hip or sacroiliac joint.

FIGURE 6-4 Bragard sign. The examiner dorsiflexes the

patient’s foot at the point when the patient
begins to experience pain as the leg is being
raised. Worsening pain may indicate increased
nerve root tension.

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 FIGURE 6-5 Femoral stretch test. With the patient in a
prone position, the affected leg is gently
lifted off the table and then flexed at
the knee. Pain in the anterior thigh may indicate L2 to
L4 root compression.

General Physical Examination lesions consistent with zoster infection,

A general examination should also be
performed to look for evidence of a
systemic etiology or more serious spine
pathology. Tenderness or masses felt
on palpation of the abdomen may
indicate intraabdominal pathology,
whereas flank tenderness suggests gen-
itourinary tract disease. As noted previ-
ously, fever may indicate the presence
of infection but is often absent in
patients with epidural abscess. Inspec-
tion of the skin may reveal herpetic
while tufts of hair in the sacral region
may be indicative of an underlying
vertebral anomaly. Local tenderness
over the spine is nonspecific and may
occur in numerous disorders, but may
indicate a vertebral compression frac-
ture in the presence of kyphosis and a
history of sudden back pain with well-
defined onset. A focal muscle mass in
the spinal region may appear to be a
muscle spasm, but it may actually
represent local myoedema, as one

FIGURE 6-6 Patrick test (flexion, abduction, external rotation

[FABER] test). While the patient is supine, the
lateral ankle of the affected leg is placed on
the contralateral knee. The affected knee is then slowly brought
down to the examination table. Pain during this maneuver is
suggestive of pathology in the hip or sacroiliac joint.

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 Low Back Pain

KEY POINTS
h The presence of multiple
nonphysiologic findings
suggests a nonorganic
etiology that may be
due to secondary gain,
psychosocial issues, or
other factors.
h In the absence of red
flags, imaging studies
should not be obtained
in patients with low
back pain of a duration
of less than 6 weeks.
study found that the mass is electrically
silent with needle EMG examination.9,21
Nonphysiologic Back Pain
While some degree of pain-related
giveway weakness or exaggerated find-
ings may be seen in patients with true
spine pathology, other more objective
signs may sometimes be found on the
examination that do support the pres-
ence of a structural and symptomatic
lesion. However, the presence of mul-
tiple nonphysiologic findings sug-
gests a nonorganic etiology that may
be due to secondary gain, psychoso-
cial issues, or other factors. In a classic
but controversial study, Waddell 22
established five signs that can be
elicited in the office and used as a
screening tool to identify patients with
nonorganic low back pain (Table 6-3).
Of these signs, overreaction was thought
to be most important, although non-
physiologic tenderness over the spine
was more common in some of the study
groups.22 A patient has a positive
screen if three of the five signs are
present. Subsequent analyses of the
original study have resulted in mixed
findings regarding the validity of these
signs, although a few studies have shown
that they may be predictive of treat-
ment outcome in specific settings.23Y26
DIAGNOSTIC STUDIES
A number of diagnostic tests may be
helpful in the evaluation of low back
pain, especially when performed at the
appropriate time.
Imaging Guidelines
According to guidelines set by the
American College of Physicians and
American Academy of Family Physi-
cians, in the absence of red flags,
imaging studies should not be obtained
in patients with low back pain of less
than 6 weeks duration.27,28 Specifically,
unless there is evidence of progressive
or severe neurologic deficits, fever,
acute trauma, sudden back pain with
spinal tenderness, or a strong clinical
suspicion for an underlying systemic
disorder, early imaging studies are not
warranted and result in increased costs
and possibly unnecessary surgery. These
recommendations are based on system-
atic reviews and individual studies that
found no significant change in out-
comes, clinical decision making, or
patient satisfaction scores when early
imaging was performed in patients with

a
TABLE 6-3 Signs Indicating Nonorganic Causes of Low Back Pain

b Overreaction to the examination

b Tenderness to light touch (eg, slight pinch in the lower back)
b Nonlocalizable tenderness that is distributed over a wide area
b Exacerbation of pain with placement of pressure on top of head
b Exacerbation of pain with simulated rotation of spine
b Giveway weakness of multiple muscles
b Nondermatomal sensory changes
b Distraction (pain present with direct straight legYraising test, but not when
leg is raised for plantar reflex evaluation)
a
Data from Waddell G, Spine (Phila Pa 1976).22 journals.lww.com/spinejournal/Abstract/1987/
09000/1987_Volvo_Award_in_Clinical_Sciences__A_New.2.aspx.

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low back pain.27,29Y32 Some studies even
reported a tendency toward a more
favorable outcome at 3 months and
increased sense of well-being for those
who underwent conservative care with-
out imaging studies compared to those
who did have early imaging.27,30,32
Other considerations include the risks
of radiation exposure that accompany
the use of routine imaging studies.
Lumbar Radiography
Although plain film radiography of the
lumbar spine is readily available and
cheaper than more advanced imaging
studies, the information provided is
limited to the bony spine and its
alignment. In the setting of acute
trauma, diffuse vertebral disease (eg,
ankylosing spondylitis), or when risk
factors are present for spinal fracture,
the use of plain films may be warranted.
However, the sensitivity for malignancy
or infection is low.33 Another drawback
is that a significant risk of radiation
exposure exists, particularly in women
because of the proximity of the repro-
ductive organs. It is estimated that the
radiation exposure to female gonads
from a single plain film of the lumbar
spine is equivalent to that of having a
daily chest radiograph for several
years.27,32 Flexion/extension plain films
may provide additional information on
stability, but these are usually reserved
for surgical evaluation.
Magnetic Resonance Imaging
and Computed Tomography
MRI of the lumbar spine is the study of
choice for neurologic back pain be-
cause it allows for optimal visualiza-
tion of the spinal cord (specifically the
conus medullaris), nerve roots, and
intervertebral disks (Figure 6-7). It is
also recommended over other studies
when cancer and infection are sus-
pected.32 Gadolinium is typically not
necessary unless intradural or lepto-
Continuum (Minneap Minn) 2017;23(2):467–486
Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
KEY POINT
meningeal disease is suspected. Be- h MRI of the lumbar spine
cause of the increased resolution, is the study of choice for
however, incidental degenerative spine neurologic back pain
changes unrelated to the pain are com- because it allows for
monly seen. In one systematic review, optimal visualization of
disk degeneration was seen in more than the conus medullaris,
one-third of asymptomatic 20-year-old nerve roots, and
individuals with a 12% to 16% increase intervertebral disks.
in prevalence per decade up to the age
of 50 years; the increase was more
gradual in the older population, reach-
ing 96% in 80-year-old patients.34
CT may be more sensitive than MRI in
detecting bony abnormalities and frac-
tures but is inferior in visualization of the
neural structures. CT is usually reserved
for patients with contraindications for
MRI, such as in patients who have im-
planted devices that are MRI incompat-
ible or in those with a history of metallic
hardware from prior spine surgeries
that may result in marked artifact.
Computed Tomography
Myelography
CT myelography is also not as sensi-
tive as MRI for detection of nerve root
or spinal cord lesions and is a more
invasive procedure with significant
risks for complications and radiation
exposure. However, in preparation for
surgery it may be complementary, espe-
cially if metallic hardware exists from
prior surgeries that obscures visualiza-
tion of the anatomy on MRI.
Electromyography
EMG is a valuable tool in the evaluation
of patients with radiculopathy as it can
confirm its presence and help deter-
mine localization, acuity, and severity of
the nerve root lesion. The needle ex-
amination is the most important part of
the study as the demonstration of
fibrillation potentials in a myotomal
distribution and paraspinal muscles is
the main method of identifying an
active radiculopathy. Of note, however,
abnormalities isolated to the paraspinal
ContinuumJournal.com 477
 Low Back Pain

KEY POINT
h The demonstration of
fibrillation potentials in
a myotomal distribution
on needle EMG is
the main method
of identifying an
active radiculopathy.

FIGURE 6-7 MRI showing spinal canal stenosis. A, Sagittal T2-weighted MRI of the
lumbar spine shows multilevel degenerative changes most severe at
L2–L3 with facet and ligamentous hypertrophy as well as a central disk
herniation resulting in severe central canal narrowing (white arrows). B, This is further
demonstrated on the axial image, which also shows bilateral severe neural foraminal
narrowing (red arrow points to the left foraminal stenosis).

muscles are insufficient for the diag-
nosis of radiculopathy as fibrillation
potentials can be seen in asymptomatic
individuals (eg, older patients) or those
with a history of spine surgery given the
possibility of local incisional denerva-
tion. Conversely, the absence of fibril-
lation potentials does not exclude the
possibility of a radiculopathy due to
overlap in innervation, sampling error,
and reinnervation. Although nerve con-
duction studies are not as critical as the
needle examination in a radiculopathy
evaluation, an absent H reflex may help
in pointing toward an S1 lesion.
EMG can also exclude the possibility
of potential mimics such as a general-
ized polyneuropathy or focal mononeuro-
pathy. However, because of technical
considerations, a radicular lesion that
affects sensory fibers in isolation (eg,
sensory radiculopathy) cannot be
detected with this procedure. This is
because the intraspinal canal portion of
the sensory nerve root that would be
affected by a disk herniation or other
478 ContinuumJournal.com
degenerative spine pathology cannot
be directly evaluated with routine nerve
conduction studies. Also, the needle
examination should not be performed
within 3 to 4 weeks of symptom onset
as this is insufficient time for develop-
ment of fibrillation potentials. EMG is
best used in patients with muscle weak-
ness, prior surgery, acute on chronic
disease, multilevel root involvement, or
when an alternative or superimposed
diagnosis is being considered.
Other Studies
For patients with suspected malignancy
or an underlying systemic disorder,
erythrocyte sedimentation rate, complete
blood cell count, urinalysis, and other
disease-appropriate laboratory studies
should be considered. However, these
tests are not part of the routine evaluation.
TREATMENT
For patients presenting with acute low
back pain with or without radicu-
lopathy, the main goals of treatment
April 2017

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.


are pain control and preservation of
function. In the absence of red flags,
which would require the initiation of
urgent disease-appropriate treatment,
conservative management for most
cases of acute low back pain is sup-
ported by a favorable prognosis regard-
less of pain type, although recurrence
rates range from 23% to 80%.3,35
Musculoskeletal Low Back Pain
Non-narcotic oral analgesics (eg, non-
steroidal anti-inflammatory drugs
[NSAIDs] and muscle relaxants) and
a return to usual activity (mobiliza-
tion) are the primary recommendations
for early treatment of acute musculo-
skeletal back pain (Table 6-4). For
those with severe pain, short periods
of bed rest (1 to 2 hours at a time)
may be needed but should be mini-
mized, as studies have shown that pa-
tients who are told to remain active
report improved pain relief and func-
tional status compared to those who
are recommended bed rest.36 Also, pa-
tients should be instructed to avoid
KEY POINTS
heavy lifting (nothing more than a h In the absence of red
gallon of milk) and other exertional flags, conservative
activities that can aggravate the pain management for most
during the acute pain period. Educa- cases of acute low back
tion and reassurance that up to 70% pain is supported by a
to 90% of cases do improve with time favorable prognosis
are an important part of the initial regardless of pain type.
visit as well (Figure 6-8).37,38 h Non-narcotic oral
Follow-up at 4 weeks with reas- analgesics and a return
sessment for the emergence of red to usual activity are
flags may be done for patients with the primary
persistent symptoms. If none are iden- recommendations for
tified, continued conservative care early treatment of
with the addition of physical therapy acute musculoskeletal
back pain.
that includes back-strengthening exer-
cises and spinal manipulation may be
considered. However, a recent study
found no meaningful benefit when
physical therapy was performed dur-
ing the acute phase (first 4 weeks)
compared to usual care.39 Massage
therapy (short-term benefit) may also
be helpful. If no recovery is seen at 6
to 8 weeks, the patient should again
be reevaluated for red flags with
consideration of imaging studies at
that time. For symptomatic relief,

TABLE 6-4 Conservative Treatment for Acute Low Back Pain

b Medications (Level of Evidencea)

Nonsteroidal anti-inflammatory drugs (good)
Muscle relaxants (good)
Applied heat (moderate)
Antiepileptic drugsb: gabapentin and topiramate (moderate)
Acetaminophen (limited)
b Self-Care
Return to usual activity/mobilization
Short periods of bed rest (1 to 2 hours maximum) if pain is severe
Avoid heavy lifting (nothing heavier than a gallon of milk)
Lumbar support pillow for travel
a
Rating system based on expert panel review: Good = multiple high-quality studies; moderate =
at least one high-quality study; limited = at least one adequate study.
b
Recommended treatment for radiculopathy.

Continuum (Minneap Minn) 2017;23(2):467–486 ContinuumJournal.com 479

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
 Low Back Pain

FIGURE 6-8 Treatment algorithm for acute low back pain.

AEDs = antiepileptic drugs; CT = computed tomography; EMG = electromyography;
MRI = magnetic resonance imaging; NSAIDs = nonsteroidal anti-inflammatory drugs.

480 ContinuumJournal.com April 2017

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.


switching to another non-narcotic
analgesic or a combination regimen
of medications and physical modali-
ties (eg, NSAIDs, massage, and yoga)
may be helpful. Otherwise, conserva-
tive care is continued.
Radiculopathy
The natural history of radiculopathy is
similar to that of musculoskeletal low
back pain, with a favorable outcome
reported by 70% to 88% of patients at
3 months.40,41 It follows then that for
patients with radiculopathy who have
no significant motor weakness or red
flags, the treatment algorithm for
acute musculoskeletal pain may be
applied with additional therapeutic
options such as the use of antiepi-
leptic medications for neuropathic pain.
Systematic reviews have shown that
both gabapentin and topiramate resulted
in improved pain compared to placebo
and were overall well tolerated.42
Systemic steroids may also be con-
sidered, but most studies have shown
no significant benefit in pain or disabil-
ity for patients with radiculopathy or
musculoskeletal low back pain. However,
a recent randomized trial that included
269 patients with acute radiculopathy
associated with a herniated disk found
that a 15-day course of oral prednisone
(60 mg, 40 mg, and 20 mg for 5 days
each) resulted in improved function at 3
and 52 weeks, but no significant change
in pain or long-term surgery rate.43
On the other hand, epidural steroid
injections have been found to provide
short-term pain relief (up to 3 months)
for radicular leg pain with an increased
likelihood of a positive response when
administered by a transforaminal ap-
proach.44,45 Epidural steroid injections
may also reduce short-term risk for
surgery compared to placebo.45,46
However, interpretation of studies
evaluating the benefit of epidural
steroid injections are difficult as re-
Continuum (Minneap Minn) 2017;23(2):467–486
Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
KEY POINTS
sults vary depending on approach h Epidural steroids may
used, therapeutic intervention chosen provide short-term pain
for comparison, and baseline inclusion relief for radiculopathic
criteria. More recently, epidural ste- pain, especially when
roid injections have come under close administered by a
scrutiny because of rising health care transforaminal
costs and the 2012 fungal outbreak approach.
related to contaminated compounded h Patients with
injectable methylprednisolone, which radiculopathy who fail to
affected more than 700 patients.47 respond to any treat-
Reports of other serious side effects ment after
including paralysis, nerve damage, 6 weeks should be
and death have prompted the US reassessed for red flags
Food and Drug Administration (FDA) and undergo MRI.
to add a warning label to epidural
steroid injection products.48 While a
subset of patients may respond favor-
ably, given the lack of clear long-term
benefit and potential risks of the
procedure, the routine use of epidural
steroid injections is still considered
controversial and is not recommended
as a first-line therapy for patients with
radiculopathy.
As in patients with musculoskel-
etal low back pain, patients with ra-
diculopathy who fail to respond to
any treatment after 6 weeks should
be reassessed for red flags and un-
dergo imaging studies, preferably MRI
(Figure 6-8). If nondiagnostic, the
next step would be EMG. If the EMG
demonstrates a well-localized nerve
root lesion with evidence of active
motor axon loss changes, surgical
evaluation may be considered. How-
ever, if no evidence of correlating
structural pathology exists, then con-
tinued conservative management is
recommended unless clinical worsen-
ing or persistence of severe pain and
sensory symptoms occurs. Clinical and
radiographic improvement is seen in
most patients with radiculopathy at
6 months to 1 year, with MRI studies
demonstrating spontaneous regression
of herniated disk changes in as early
as 2 months.49,50 Of note, patients
with significant motor weakness (eg,
ContinuumJournal.com 481
 Low Back Pain
KEY POINTS
h The management of
chronic low back pain
should include a careful
review of previous
treatments and
responses as well as
an evaluation for
contributing psychosocial
factors.
h According to an
American Academy of
Neurology position
statement, the risks of
opioids in treating
noncancerous low back
pain outweigh
the benefits.
482 ContinuumJournal.com
Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
footdrop or hip flexor weakness)
should undergo early imaging studies
(at presentation) as surgical interven-
tion may be needed to prevent perma-
nent deficits.
Lumbar Spinal Stenosis
As chronic and progressive degenera-
tive changes are the main pathophysi-
ology of spinal stenosis, the natural
history is somewhat less favorable than
that seen with musculoskeletal or radic-
ular back pain, although the severity of
stenosis seen radiographically often
does not correlate with clinical findings.
One study found that 70% of patients
with spinal stenosis reported the same
degree of symptoms at 4-year follow-
up, 15% clinically worsened, and the
remaining 15% showed improvement.51
Medical management is challenging
as most studies show little to no benefit
for therapeutic modalities commonly
used for low back pain. In combination
with other conservative measures,
gabapentin has a small effect on pain
and on a patient’s ability to walk longer
distances, and comprehensive physical
therapy may result in perceived recov-
ery, but a recent randomized trial
showed no significant benefit with
epidural steroid injections over epidural
lidocaine alone in patients with spinal
stenosis.11,52 Surgical evaluation is of-
ten warranted in patients with progres-
sive or disabling symptoms.
Chronic Low Back Pain
The management of chronic low back
pain, which by definition persists for
more than 12 weeks, should include a
careful review of previous treatments
and responses as well as an evaluation
for contributing psychosocial factors,
which may be addressed with referral
to psychiatry and counseling. As with
all types of back pain, an evaluation
for red flags should also be performed,
and imaging studies should be consid-
ered if a new or emerging pathology is
suspected. Oral analgesics found to
be helpful include NSAIDs, antiepi-
leptics (gabapentin and topiramate),
duloxetine, and muscle relaxants.42,53
Botulinum toxin may also be an
option, as two randomized trials includ-
ing 81 patients with chronic low back
pain found that injection of botulinum
toxin A into the lumbar paraspinal
muscles resulted in improved pain at 3
to 4 weeks and again at 8 weeks com-
pared to normal saline injections.54,55
The use of complementary and alter-
native medicine practices in chronic
low back pain have also been studied
with benefits in pain or disability seen with
yoga, massage, and acupuncture.56Y58
Short-term pain reduction has also been
seen with herbal preparations, specifi-
cally willow bark extract (containing
salicin 120 mg/d to 240 mg/d orally)
and devil’s claw (containing harpagoside
50 mg/d to 100 mg/d orally).59,60 How-
ever, these supplements are not regu-
lated by the FDA, and their long-term
safety has not been established.
While some studies have found that
opioids may provide short-term pain
relief for patients with chronic low back
pain, no increased benefit has been
seen when compared to NSAIDs and
antidepressants.61 In addition, the po-
tential dangers of addiction and over-
dose are major concerns, which
resulted in a position article from the
American Academy of Neurology
(AAN) stating that the risks of opioids
in treating noncancerous low back pain
outweigh the benefits.62
Insufficient evidence exists to sup-
port the use of radiofrequency ablation,
acetaminophen, lidocaine patches, anti-
depressants other than duloxetine,
spinal manipulation, Pilates, and trans-
cutaneous electrical nerve stimulation
for chronic low back pain. However,
these therapies are generally safe when
used as directed and may be considered
April 2017

in refractory cases.53 Optimal treatment
of chronic back pain consists of a
multidisciplinary approach that includes
an active exercise regimen, psychoso-
cial support, and cognitive-behavioral
therapy. A recent systematic review
found that a “biopsychosocial” ap-
proach to the treatment of low back
pain, which includes all of these com-
ponents, was more effective than stan-
dard exercise therapy, usual care, and
normal activities.63 Risk factors associ-
ated with transformation from acute to
chronic back pain include psychosocial
factors (anxiety, depression, job dissat-
isfaction), pending litigation, worker’s
compensation claims, tobacco use, and
prior history of low back pain.64,65
Surgery
Current indications for early surgery
include cauda equina compression and
radiculopathy with rapidly progressive
or severe neurologic deficits. Surgery
may also be considered in patients with
spinal stenosis, as systematic reviews
suggest that surgical decompression
results in better outcomes than non-
operative management, although re-
sults are mixed and confounded by
marked crossover rates.66,67 Patients
with radiculopathy who have milder
deficits associated with a structural
lesion on MRI or active denervation
on EMG who fail to respond to
conservative treatment at 4 to 6 weeks
may be referred for surgery as well. For
patients with musculoskeletal back
pain associated with nonspecific de-
generative changes, response to sur-
gery has been found to be no different
than intensive rehabilitation, but is
slightly superior to standard care.68
Surgical approaches vary depending
on the pathology and degree of struc-
tural changes, but most patients with
spinal stenosis undergo decompressive
laminectomy, whereas diskectomy is
performed for herniated disks.
Continuum (Minneap Minn) 2017;23(2):467–486
Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
KEY POINTS
CONCLUSION h Current indications for
Growing evidence suggests that low early surgery include
back pain in general should be con- cauda equina
sidered a chronic condition that is compression and
characterized by periodic relapses and radiculopathy with
remissions. However, a systematic ap- rapidly progressive or
proach that incorporates a careful his- severe neurologic
tory and neurologic examination with deficits.
evidence-based guidelines can result in h For patients with
optimal care for the patient and a musculoskeletal back
positive impact on society. pain associated with
nonspecific degenerative
changes, response to
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