Low back pain

Differential diagnosis

1. Mechanical causes
a. Idiopathic (Strain, sprain)
b. Spondylosis (Disk, annulus, facet)
c. Compression fracture
d. Traumatic fracture
e. Alignment disorders (Kyphosis, scoliosis,spondylolisthesis)
2. Non mechanical causes
a. Malignancy
b. Infection
c. Inflammatory spondyloarthropathy (ankylosing spondylitis, psoriatic spondylitis, Reiter’s
syndrome, inflammatory bowel disease.
d. Osteochondrosis
e. Paget’s disease of bone
3. Referred pain
a. Pelvic disease (prostatitis, endometriosis, pelvic inflammatory disease)
b. Renal disease (Kidney stones, pyelonephritis, perinephric abscess)
c. Aortic aneurysm
d. Gastrointestinal disease (Pancreatitis, cholecystitis, penetrating ulcer)

Red Flags in Low Back Pain

1. Cancer related red flags with Low Back Pain

a. Hx of cancer
b. Unexplained weight loss >10kg within 6 months
c. Age >50yo or <18
d. Failure to improve with therapy
e. Pain persist for more than 4 – 6 weeks
f. Night pain or pain at rest
2. Infection related red flags with Low Back Pain
a. Persistent fever ( poor sensitivity for spinal infection)
b. Hx of IV DU
c. Severe pain
d. Lumbar spine surgery within the last year
e. Recent Bacterial Infection
i. UTI
ii. Cellulitis
iii. Pneumonia
iv. Wound at spine region
f. Immunocompromised states
 i. Corticosteroids
ii. Organ Transplant
iii. DM
iv. HIV
v. Rest Pain
3. Cauda Equina Syndrome Related Red Flags with Back Pain
a. Urinary incontinence / retention
b. Saddle anaesthesia
c. Anal spinter tone decreased / Fecal incontinence
d. Bilateral lower extremity weakness or numbness
e. Progressive neurologic deficit
i. Major motor weakness
ii. Major sensory deficit
4. Significant HNP Red Flags
a. Major Muscle weakness (power 3 of 5 or less)
b. Foot drop
5. Vertebral fracture related Red Flags with Low Back Pain
a. Prolonged Corticosteroid use
b. Age >70yo
c. Hx of Osteoporosis
d. Mild Trauma Over 50yo or with Osteoporosis
e. Recent significant trauma at any age
i. Eject from vehicle
ii. Fall from substantial height
6. Abdominal aortic aneurysm red flags
a. Abdominal pulsating mass
b. Artherosclerotic vascular disease
c. Pain at rest or nocturnal pain
d. Age >60yo
7. Red flags (General)
a. Vertebral tenderness
b. Limited spine ROM

During long case

Symptoms :

40yo man present with a 2 yr hx of chronic low back pain. In the past 1 week he had exacerbation of his
symptoms and intermittent pain radiating down his right leg

History :

1. Recent trauma (possibility of fracture)

2. Red Flag signs
a. Thoracic pain
b. Fever and unexplained weight loss
c. Bladder or bowel dysfunction
d. History of Ca
e. Ill health or presence of other medical illness
f. Progressive neurological deficit
g. Disturbed gait, saddle anaesthesia
h. Age of onset (<20 yo, >55yo)
3. Yellow Flags signs (psychosocial factors) – indicating long term chronicity and disability
a. Negative attitude that back pain is harmful or potentially severely disabling
b. Fear avoidance behavior and reduced activity levels
c. Expectation that passive rather than active treatment will be beneficial
d. Tendency to depression, low morale, social withdrawal
e. Social or financial problems
4. Examination
a. Look for reduced spinal range of motion
b. Reduced SLR
c. Positive neural stretch test
d. Neurological deficit (sensory, motor, reflex impairment)
e. Distribution of paraesthesias or sensory loss
f. Reduced ankle and great toe dorsiflexion, knee and ankle reflexes
5. Risk factors :
a. Overweight
b. Sedentary lifestyle
c. Smoking
d. Heavy physical work
e. Repetitive lifting
f. Twisting
g. Prolong standing in awkward posture