Evaluation of Low Back Pain in Adults

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Evaluation of low back pain in adults

Authors: Stephanie G Wheeler, MD, Joyce E Wipf, MD, Thomas O Staiger, MD, Richard A Deyo, MD, MPH, Jeffrey G Jarvik, MD, MPH
Section Editor: Steven J Atlas, MD, MPH
Deputy Editor: Lisa Kunins, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2021. | This topic last updated: Jan 06, 2021.
INTRODUCTION
It is estimated that up to 84 percent of adults have low back pain at some time in their lives [1,2]. For many individuals, episodes of back
pain are self-limited. Patients who continue to have back pain beyond the acute period (four weeks) have subacute back pain (lasting
between 4 and 12 weeks) and may go on to develop chronic back pain (persists for ≥12 weeks) [3]. Rarely, back pain is a harbinger of serious
medical illness.
This discussion will focus on an approach to the initial evaluation, including diagnostic tests, of a patient presenting with low back pain in
the primary care setting. The treatment of acute, subacute, and chronic low back pain are discussed separately. (See "Treatment of acute
low back pain" and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low
back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Surgical treatment".)
TERMINOLOGY
Several terms are used to describe conditions related to the back, based upon radiologic findings (eg, spondylosis), physical findings
(radiculopathy), and symptoms (sciatica). These terms are defined in the table ( table 1).
EPIDEMIOLOGY
In 2010, back symptoms were the principal reason for 1.3 percent of office visits in the United States [4]. Spinal disorders accounted for 3.1
percent of diagnoses in outpatient clinics.
Prevalence — The prevalence of back pain has been estimated with surveys [1,5]. A 2012 systematic review estimated that the global point
prevalence of activity-limiting low back pain lasting for more than one day was 12 percent and the one-month prevalence was 23 percent
[6].
Other survey estimates of the prevalence of low back pain have ranged from 22 to 48 percent, depending on the population and definition
[2,7-9]. For example, the 2002 National Health Interview Survey found that 26 percent of respondents reported low back pain lasting at least
one day in the last three months [7].
Risk factors — Risk factors associated with back pain complaints include smoking, obesity, age, female gender, physically strenuous work,
sedentary work, psychologically strenuous work, low educational attainment, Workers' Compensation insurance, job dissatisfaction, and
psychologic factors such as somatization disorder, anxiety, and depression [2,8,10-15].
ETIOLOGIES
Although there are many etiologies of low back pain ( table 2), the majority of patients seen in primary care will have nonspecific low back
pain.
Nonspecific back pain — The vast majority of patients seen in primary care (>85 percent) will have nonspecific low back pain, meaning that
the patient has back pain in the absence of a specific underlying condition that can be reliably identified [16-18]. Many of these patients may
have musculoskeletal pain [3]. Most patients with nonspecific back pain improve within a few weeks. (See "Treatment of acute low back
pain", section on 'Prognosis'.)
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Serious systemic etiologies — Among patients who present with back pain to primary care settings, less than 1 percent will have a serious
systemic etiology (cauda equina syndrome, metastatic cancer, and spinal infection) [5,19]. Almost all patients with these conditions will have
risk factors or other symptoms [18].
● Spinal cord or cauda equina compression – There are many causes of cauda equina syndrome, the most common being herniation of
the intervertebral disc. One systematic review found that cauda equina syndrome was caused by herniation of the intervertebral disc in
22.7 percent of cases, ankylosing spondylitis in 15.9 percent, lumbar puncture in 15.9 percent, trauma in 7.6 percent, malignant tumor
in 7.2 percent, benign tumor in 5.7 percent, and infection in 5.3 percent [20]. While the incidence of cord compression in patients known
to have cancer varies depending on the cancer, among patients who are diagnosed with cord compression, it is the initial manifestation
of malignancy in 20 percent [21]. Metastatic disease from any primary cancer can cause cord compression. (See "Clinical features and
diagnosis of neoplastic epidural spinal cord compression", section on 'Epidemiology' and "Clinical features and diagnosis of neoplastic
epidural spinal cord compression", section on 'Pathophysiology'.)
Pain is usually the first symptom of cord compression, but motor (usually weakness) and sensory findings are present in the majority of
patients at diagnosis. Bowel and/or bladder dysfunction are generally late findings. Early diagnosis and treatment improves outcomes.
(See "Clinical features and diagnosis of neoplastic epidural spinal cord compression", section on 'Clinical features' and "Treatment and
prognosis of neoplastic epidural spinal cord compression", section on 'Importance of early detection'.)
● Metastatic cancer – The bone is one of the most common sites of metastasis. A history of cancer (excluding nonmelanoma skin
cancers) is the strongest risk factor for back pain from bone metastasis [22]. Among solid cancers, metastatic disease from breast,
prostate, lung, thyroid, and kidney cancers account for 80 percent of skeletal metastases. Approximately 60 percent of patients with
multiple myeloma have skeletal lytic lesions present at diagnosis. (See "Epidemiology, clinical presentation, and diagnosis of bone
metastasis in adults", section on 'Epidemiology' and "Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis",
section on 'Skeletal surveys'.)
Pain is the most common symptom. In patients with a history of cancer, sudden, severe pain raises concern for pathologic fracture.
Patients may also have neurologic symptoms from either spinal cord compression or spinal instability. (See "Epidemiology, clinical
presentation, and diagnosis of bone metastasis in adults", section on 'Clinical presentation'.)
● Spinal epidural abscess – Spinal epidural abscess is a rare but serious cause of back pain. Initial symptoms (eg, fever and malaise) are
often nonspecific; over time, localized back pain may be followed by radicular pain and, left untreated, neurologic deficits. Risk factors
include recent spinal injection or epidural catheter placement, injection drug use, and other infections (eg, contiguous bony or soft
tissue infection or bacteremia). Immunocompromised patients may also be at higher risk. Treatment of spinal epidural abscess is
reviewed in detail elsewhere. (See "Spinal epidural abscess", section on 'Management'.)
● Vertebral osteomyelitis – The majority of patients with vertebral osteomyelitis will present with back pain, which gradually increases
over weeks to months [23]; fever may or may not be present. The intervertebral disc may also be become infected (discitis), and the
clinical presentation (positional discomfort, pain to palpation, neurologic signs/symptoms) may vary depending upon the extent of the
infection. (See "Vertebral osteomyelitis and discitis in adults", section on 'Clinical features'.)
The incidence of vertebral osteomyelitis generally increases with age, and men are more commonly affected than women. Many cases
are thought to be health care-related or postprocedural from hematogenous spread of bacteremia. Less specific risk factors include an
immunocompromised state and injection drug use. (See "Vertebral osteomyelitis and discitis in adults", section on 'Epidemiology' and
"Vertebral osteomyelitis and discitis in adults", section on 'Pathogenesis'.)
Management of vertebral osteomyelitis is discussed in detail elsewhere. (See "Vertebral osteomyelitis and discitis in adults", section on
'Treatment'.)
Less serious, specific etiologies — Less than 10 percent of patients who present in primary care settings with low back pain will have less
serious but specific etiologies for their pain [19,24].
● Vertebral compression fracture – Approximately 4 percent of patients presenting in the primary care setting with low back pain will
have a vertebral compression fracture [19]. While some produce no symptoms, other patients present with acute onset of localized back
pain which may be incapacitating. There may be no history of preceding trauma. Risk factors for osteoporotic fracture include advanced
age and chronic glucocorticoid use ( table 3). A history of an osteoporotic fracture is a risk factor for subsequent fractures, which can
be mitigated by pharmacologic therapy. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and
treatment", section on 'Clinical manifestations' and "Osteoporotic fracture risk assessment" and "Overview of the management of
osteoporosis in postmenopausal women", section on 'Post-fracture'.)
Approximately 3 to 4 percent of patients who present in primary care settings with low back pain have a symptomatic disc herniation or
spinal stenosis [19].
● Radiculopathy – Radiculopathy refers to symptoms or impairments related to a spinal nerve root. Damage to a spinal nerve root may
result from degenerative changes in the vertebrae, disc protrusion, and other causes. The clinical presentations of lumbosacral
radiculopathy vary according the level of nerve root or roots involved. Over 90 percent are L5 and S1 radiculopathies [25]. Patients
present with pain, sensory loss, weakness, and/or reflex changes consistent with the nerve root involved; these are summarized in the
table and discussed in more detail separately ( table 4). Testing for lumbar nerve root compression is shown in a figure ( figure 1).
Many patients with symptoms of acute lumbosacral radiculopathy improve gradually with supportive care. (See "Acute lumbosacral
radiculopathy: Pathophysiology, clinical features, and diagnosis", section on 'Pathophysiology and etiology' and "Acute lumbosacral
radiculopathy: Pathophysiology, clinical features, and diagnosis", section on 'Clinical presentations' and "Acute lumbosacral
radiculopathy: Treatment and prognosis", section on 'Prognosis'.)
Sciatica is a nonspecific term used to describe a variety of leg or back symptoms. Usually, sciatica refers to a sharp or burning pain
radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or
ankle) [26]. Most sciatica is attributable to radiculopathy at the L5 or S1 level from a disc disorder.
● Spinal stenosis – Lumbar spinal stenosis is most often multifactorial. Spondylosis (degenerative arthritis affecting the spine)
spondylolistheses, and thickening of the ligamentum flavum are the most common causes, typically affecting patients >60 years (
figure 2). (See "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Etiologies'.)
Ambulation-induced pain localized to the calf and distal lower extremity resolving with sitting or leaning forward ("pseudoclaudication"
or "neurogenic claudication") is a hallmark of lumbar spinal stenosis. Other symptoms of lumbar spinal stenosis can include back pain
and sensory loss and weakness in the legs, though many patients may present with a normal neurologic exam. Symptoms of
neurogenic claudication can usually be distinguished from vascular claudication ( table 5). Rare patients develop a cauda equina
syndrome. Patients often have symptoms only when active. Most patients with spinal stenosis related to osteoarthritis will have stable
symptoms over time. A trial of conservative, nonsurgical treatment is the initial therapy for most patients [27]. (See "Lumbar spinal
stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Clinical presentation' and "Lumbar spinal stenosis: Treatment
and prognosis", section on 'Prognosis' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Nonsurgical treatment'.)
Other etiologies
● Ankylosing spondylitis – Among patients who present in primary care settings for back pain, it is estimated that approximately 0.5
percent will have ankylosing spondylitis [19,24]. It is most commonly diagnosed in men under the age of 40 years. (See "Clinical
manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on
'Epidemiology'.)
Almost all patients report back pain, which often has characteristics suggesting an inflammatory etiology (morning stiffness,
improvement with exercise, pain at night) [3]. Patients may also have extraskeletal disease manifestations (eg, uveitis). (See "Clinical
manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on
'Musculoskeletal symptoms and findings' and "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and
nonradiographic axial spondyloarthritis) in adults", section on 'Extraarticular manifestations and comorbidities'.)
● Osteoarthritis – Low back pain may be a symptom of osteoarthritis of the facet joints spine. Patients may also complain of hip pain,
either from osteoarthritis of the hip or referred pain from the spine. Osteoarthritis most commonly presents in patients over the age of
40. Pain is typically exacerbated by activity and relieved by rest ( table 6). Osteoarthritis can lead to spinal stenosis. (See "Clinical
manifestations and diagnosis of osteoarthritis", section on 'Facet joint'.)
● Scoliosis and hyperkyphosis – Back pain can be associated with scoliosis and hyperkyphosis. (See "Adolescent idiopathic scoliosis:
Management and prognosis", section on 'Outcome' and "Overview of hyperkyphosis in older persons", section on 'Other health-related
consequences'.)
● Psychologic distress – Psychologic distress (eg, depression or somatization) may contribute to the severity symptoms of low back pain
or may be a cause of nonorganic back pain [3]. (See "Somatic symptom disorder: Epidemiology and clinical presentation", section on
'Clinical presentation'.)
● Etiologies outside the spine – Low back pain may be a symptom of problems outside the back. Examples of other etiologies include
pancreatitis, nephrolithiasis, pyelonephritis, abdominal aortic aneurysm, or herpes zoster [3,17]. Patients generally have other
accompanying symptoms. (See "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Clinical features' and "Acute
complicated urinary tract infection (including pyelonephritis) in adults", section on 'Clinical manifestations' and "Clinical features and
diagnosis of abdominal aortic aneurysm", section on 'Clinical presentations' and "Epidemiology, clinical manifestations, and diagnosis of
herpes zoster", section on 'Clinical manifestations' and "Kidney stones in adults: Diagnosis and acute management of suspected
nephrolithiasis", section on 'Clinical manifestations'.)
There are also clinical entities that are possibly associated with low back pain symptoms:
● Piriformis syndrome – The piriformis syndrome is thought by some to be a condition in which the piriformis muscle, a narrow muscle
located in the buttocks, compresses or irritates the sciatic nerve [26,28,29].
● Sacroiliac joint dysfunction – "Sacroiliac joint dysfunction," a term to describe pain in the region of the sacroiliac joint believed to be
due to malalignment or abnormal joint movement, is a controversial topic. Diagnosing this condition is difficult due to the absence of
an agreed upon “gold standard” [30]. Tests of pelvic symmetry or sacroiliac joint movement have been shown to have low intertester
reliability [31-37], and provocative maneuvers such as fluoroscopically guided injections of the sacroiliac joint have been unreliable in
diagnosis and treatment [36,38,39]. The sacroiliac joint may be a referred site of pain, including from a degenerative disc at L5-S1,
spinal stenosis, or osteoarthritis of the hip.
● Bertolotti's syndrome – Back pain in the setting of a transitional vertebra is known as "Bertolotti's syndrome." A transitional vertebra is
a common finding on radiologic studies. It is a congenital anomaly with a naturally occurring articulation or bony fusion between the
transverse processes of L5 and the sacrum. Estimates of prevalence of transitional vertebra range from 4 to 36 percent [40]. It remains
unclear whether these individuals have a higher risk of back pain than those without such an anomaly. Generally, patients with
Bertolotti's syndrome should initially be treated similarly as patients with nonspecific back pain. Whether and when surgical
intervention is appropriate remains unclear.
INITIAL EVALUATION
The clinical evaluation of low back pain includes a history and physical to evaluate for signs or symptoms that indicate need for immediate
imaging and further evaluation. For most patients with acute back pain (<4 weeks), laboratory tests and imaging are not necessary in the
initial evaluation.
History — While it may not be possible to define a precise cause of low back symptoms for most patients, it is important to evaluate for
evidence of specific etiologies of back pain. The history should include location, duration, and severity of the pain, details of any prior back
pain, and how current symptoms compare with any previous back pain.
We also ask about constitutional symptoms (eg, unintentional weight loss, fever, or night sweats), history of malignancy, precipitants or
precipitating events, therapies attempted, neurologic symptoms (eg, weakness, falls or gait instability, numbness or other sensory changes,
or bowel/bladder symptoms), stability or progression of symptoms, history of recent bacterial infections (particularly bacteremia), recent
history or current use of injection drugs, history or current use of corticosteroid medications, and recent history of epidural or spinal
procedures.
Patients should also be evaluated for social or psychologic distress that may be contributing [3]. Potentially useful items are a history of
failed previous treatments, substance use disorder, and disability compensation. Screening for depression may be helpful. (See "Screening
for depression in adults".)
Features that may suggest underlying systemic disease include history of cancer, age >50 years, unexplained weight loss, duration of pain
>1 month, nighttime pain, and unresponsiveness to previous therapies [3]. Documented fevers, injection drug use, recent bacterial infection
(particularly bacteremia), or recent epidural or spinal instrumentation increase the suspicion of spinal infection. (See "Spinal epidural
abscess" and "Vertebral osteomyelitis and discitis in adults".)
Physical examination — In general, the purpose of the physical examination is to identify features that suggest that further evaluation is
indicated, rather than to make a primary diagnosis. The physical examination should include the following components:
● Inspection of back and posture – Inspection of the patient on physical examination can reveal anatomic abnormalities such as
scoliosis or hyperkyphosis ( table 1). (See "Overview of hyperkyphosis in older persons".)
● Palpation/percussion of the spine – Palpation and/or percussion of the back is usually performed to assess vertebral or soft tissue
tenderness. Vertebral tenderness is a sensitive, but not specific, finding for spinal infection, and may also be seen in patients with
vertebral metastases and osteoporotic compression fracture [41]. (See "Vertebral osteomyelitis and discitis in adults", section on
'Symptoms and signs'.)
● Neurologic examination – Patients should have a neurologic examination including evaluation of the reflexes, strength, sensation, and
gait. (See "The detailed neurologic examination in adults".)
For patients suspected of having a radiculopathy, neurologic testing should focus on the L5 and S1 nerve roots ( table 4), since most
clinically significant radiculopathies occur at these levels. (See "Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and
diagnosis", section on 'Physical examination'.)
● Straight leg raising – The straight leg raise and other maneuvers can be helpful in identifying whether symptoms are radicular in
nature. These are described separately. (See "Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis",
section on 'Maneuvers'.)
● Nonorganic signs (Waddell's signs) – Patients with psychologic distress that is contributing to back pain symptoms may have
associated inappropriate physical signs, also known as "Waddell's signs" ( table 7). These include patient overreaction during physical
examination, superficial tenderness, straight leg raise that improves when the patient is distracted, unexplainable neurological deficits
(eg, nondermatomal distribution of sensory loss, sudden giving way or jerky movements with motor exam, inconsistency in observed
spontaneous activity [dressing, getting off table]), and pain elicited by axial loading (pressing down on top of head, or rotating the body
at hips or shoulders) [42]. The presence of multiple Waddell's signs suggests a psychologic component to a patient's pain, although they
do not seem to be useful for predicting the ability to return to work or success of rehabilitation [3,43,44].
● Other – For patients with new or worsening urinary incontinence, we measure bladder post void residual (eg, by ultrasound) to
differentiate overflow incontinence from urge and/or stress incontinence. If a patient's history strongly suggests malignancy, we
evaluate as appropriate (eg, lymph node exam, breast exam, prostate evaluation). Other physical examination components (eg, hip
examination or examination for peripheral vascular disease) should be performed based on the history. (See "Clinical features and
diagnosis of lower extremity peripheral artery disease", section on 'Physical examination' and "Approach to the adult with unspecified
hip pain", section on 'Diagnostic approach'.)
Laboratory studies — Most patients with acute low back pain do not require any laboratory testing. In some patients with suspected
infection or malignancy, we use the erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) in addition to plain radiographs to
determine the need for advanced imaging [22,45-47]. Because of its higher sensitivity, CRP may have similar or greater value than the ESR;
however, CRP has not been similarly evaluated in the evaluation of low back pain. (See 'Risk assessment for acute back pain' below.)
The ESR and CRP are also used in the diagnosis of ankylosing spondylitis. (See "Diagnosis and differential diagnosis of axial
spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'Laboratory testing'.)
IMAGING
Limited utility of imaging — Earlier use of imaging for low back pain without associated symptoms is not associated with improved
outcomes but increases the use of invasive procedures and likely health care costs [48]. As examples:
● A 2009 systematic review and meta-analysis of six trials that compared immediate imaging (lumbosacral spine magnetic resonance
imaging [MRI], computed tomography [CT], or radiography) with usual care for patients with acute and subacute low back pain, without
signs or symptoms of infection or malignancy, found no differences in short-term (up to three months) or long-term (6 to 12 months)
outcomes for measures of patient pain or function [49].
● In subsequent observational studies:
• In patients ≥65 years with back pain without radiculopathy, there were no differences in disability at one year for patients who
received early imaging (within six weeks of the index visit) compared with those who did not [50].
• In a cohort study including 405,000 US Department of Veterans Affairs (VA) patients with nonspecific low back pain and no
concerning features for malignancy or infection, imaging with lumbar MRI within six weeks of initial presentation was associated
with a greater likelihood of back surgery (1.5 versus 0.1 percent), treatment with opioids (35 versus 29 percent), and greater costs
(USD $8000 versus $5500) at one year [48].
Additionally, imaging exams often show abnormal findings in adults without low back pain, which makes it difficult to determine which
imaging findings are clinically significant. As an example, disc herniations on MRI are seen in 22 to 67 percent of asymptomatic adults and
spinal stenosis in 21 percent of asymptomatic adults over age 60 [51-53]. Osteoarthritis is also often seen on imaging but correlates poorly
with symptoms [54]. In a study of 188 individuals 40 to 80 years old, 60 percent of males and 67 percent of females had facet joint
osteoarthritic changes on lumbar CT scans; the prevalence of radiologic facet joint osteoarthritis increased with age, but there was no
correlation with low back pain [55]. In addition, in a systematic review of 33 studies of asymptomatic adults, the prevalence of degenerative
lumbar spine changes (identified on CT or MRI) increased with age [56]. Facet joint degeneration, for example, was observed among 9
percent of adults in their 30s and 83 percent of those in their 80s. Disc degeneration was observed in 52 percent of adults in their 30s and
96 percent of those in their 80s. Most findings had monotonic increases with each decade of age. (See "Acute lumbosacral radiculopathy:
Pathophysiology, clinical features, and diagnosis", section on 'Neuroimaging' and "Lumbar spinal stenosis: Pathophysiology, clinical
features, and diagnosis", section on 'Neuroimaging'.)
Even when the radiographic findings are consistent with clinical presentation, the magnitude of radiographic findings does not necessarily
correlate with clinical severity and outcome, and clinical improvement may not correlate with resolution of the radiographic defect [57,58].
As an example, in one follow-up of a trial of 283 patients with lumbar disk herniation and sciatica who had undergone surgery, MRI at one-
year follow-up showed disk herniation in 35 and 33 percent of patients with favorable and unfavorable outcomes, respectively [58].
Some findings on MRI are clinically insignificant or of uncertain significance. These include:
● Annular fissures (tears) – Annular fissures, colloquially termed tears, are separations between the annular fibers of the intervertebral
disc or separations of annular fibers from their attachments to the vertebral bone. Several small studies found no correlation between
the presence of annular fissure and back pain [59-61]. As an example, a prospective study of asymptomatic patients found that 38
percent had evidence of annular fissures at baseline [62]. Follow-up after three years showed that annular fissures were not associated
with new back pain [59].
● Schmorl's nodes – Schmorl's nodes, representing herniation of the nucleus pulposus into the adjacent end plate, can be seen in
approximately 20 percent of MRI studies in patients without back pain ( image 1) [63]. Although Schmorl's nodes are associated with
degenerative changes in the lower back, they are not an independent risk factor for back pain [64].
● Modic changes – Modic changes (also known as degenerative endplate changes) are of unclear clinical significance. They refer to
specific signal changes in the vertebral endplate and adjacent bone marrow on a spine MRI [65]. These changes occur in 6 to 10 percent
of asymptomatic adults and are common in patients with back pain, with any type of Modic change typically reported in about 20 to 40
percent of patients [66,67]. The prevalence of Modic changes increases with age and appears to be associated with degenerative disc
changes. A systematic review found only a small number of treatment studies involving patients with Modic changes and concluded
that it is unclear whether the presence of these changes is helpful in guiding the selection of treatment options [68]. Additionally, the
type of Modic change in a single patient may progress or regress over time [69].
Modalities — The main imaging modalities to evaluate back pain are spine MRI, CT, and plain radiographs. Initial imaging is not indicated in
the majority of patients with low back pain. (See 'Indications for imaging' below.)
● Advanced imaging – For most patients with low back pain who require advanced imaging, lumbar spine MRI without contrast is
generally considered the best initial examination [70,71]. It provides axial as well as sagittal views and demonstrates discs, ligaments,
nerve roots, and epidural fat, as well as the shape and size of the spinal canal. MRI is more sensitive and specific than plain radiographs
for the detection of spinal infection and malignancy [19]. In patients where there is a suspicion for cancer, infection, or
immunosuppression, MRI is performed without and with intravenous contrast to evaluate for underlying infection or mass.
Enhancement with gadolinium also allows the distinction of scar from disc in patients with prior back surgery.
In patients who require advanced imaging but cannot undergo MRI, we generally proceed with lumbar spine CT without contrast [71].
Neither Tc-99m bone scan nor myelography are considered appropriate for the initial evaluation of patients with back pain. (See
'Infection' below and "Patient evaluation for metallic or electrical implants, devices, or foreign bodies before magnetic resonance
imaging", section on 'Assessing implants, devices, or foreign bodies for MRI'.)
● Plain radiographs – When plain radiographs are indicated, anteroposterior and lateral views of the lumbar spine are usually adequate.
Oblique and spot views substantially increases the radiation dose and adds little new diagnostic information [72]. Flexion-extension
views may be helpful in patients for whom instability is a concern.
Plain radiographs are a reasonable option for imaging in patients who have risk factors for malignancy [19], and they are often
combined with the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) for evaluation (see 'Cancer' below and 'Cancer risk'
below). Plain radiographs may also be an option for in patients with osteoporosis where the primary concern is detection of a
compression fracture [73].
Indications for imaging — The majority of patients with low back pain of less than four weeks duration do not require imaging [17]. Most
patients who present to primary care settings will have nonspecific pain without associated symptoms and will improve rapidly. (See
'Etiologies' above and "Treatment of acute low back pain", section on 'Prognosis'.)
Approximately one-quarter of patients 18 to 50 years of age with acute low back pain who underwent imaging exams had no identifiable
indication for imaging [74]. Inappropriate lumbar imaging can lead to irrelevant findings and trigger additional costly studies, unneeded
treatments, and unwarranted surgical interventions [75-77].
Joint guidelines from the American College of Physicians (ACP) and the American Pain Society explicitly recommend that "clinicians should
not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain" and reserve imaging for patients with
severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical
examination [17,18]. Guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom advise clinicians to
“not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica” [78]. The ACP provides practical
advice about when imaging studies should be considered in patients with acute low back pain ( table 8), and our recommendations below
are consistent, with the exception of imaging for suspected vertebral compression fracture. Avoiding imaging in acute low back pain has
been identified as a recommendation in the American Board of Internal Medicine's "Choosing Wisely" campaign.
Red flags — Some guidelines suggest "red flag" symptoms, which may identify patients at risk for a more dangerous cause of back pain
and represent an indication for earlier imaging exams [5,17,18,79]. There are limited data to support the use of most of the red flags as an
indication for early imaging [80]. Systematic reviews of studies that used one or more of these indications for imaging found that only a
history of cancer has been shown to increase the probability of finding spinal malignancy [81,82]. Systematic reviews have found that the
red flags associated with the highest post-test probability of a vertebral fracture were older age, prolonged use of corticosteroids, severe
trauma, and presence of contusion or abrasion [81,83].
Risk assessment for acute back pain — Among patients seen in primary care, less than one percent will have a serious systemic
etiology that requires evaluation with immediate advanced imaging ( algorithm 1). (See 'Serious systemic etiologies' above and
'Modalities' above and 'Less serious, specific etiologies' above.)
Neurologic deficits — Indications for imaging in the presence of neurologic symptoms depends upon the nature of the symptoms
and the patient's risk factors for cancer and/or an infectious etiology of back pain ( algorithm 1).
● Any patient with symptoms of spinal cord or cauda equina compression or progressive and/or severe neurologic deficits should have
immediate MRI for further evaluation and urgent specialist referral. Such symptoms and signs include new urinary retention, urinary
incontinence from bladder overflow, new fecal incontinence, saddle anesthesia, and significant motor deficits not localized to a single
nerve root. (See "Clinical features and diagnosis of neoplastic epidural spinal cord compression", section on 'Magnetic resonance
imaging of the spine' and "Spinal epidural abscess", section on 'Diagnosis'.)
● Patients with radiculopathy attributable to a single nerve root level or with stable symptoms due to spinal stenosis do not need
immediate imaging unless there is a risk of metastatic cancer or moderate to high risk of infection.
• Such patients (who have a risk of metastatic cancer or in whom there is moderate to high risk of infection) should undergo
immediate MRI. (See 'Serious systemic etiologies' above.)
• For all patients with radiculopathy attributable to a single nerve root level, we image with MRI if there is no improvement in
symptoms after four to six weeks of conservative therapy. There is no indication to re-image patients with spinal stenosis
symptoms if previous MRI was performed and symptoms are stable. (See "Acute lumbosacral radiculopathy: Pathophysiology,
clinical features, and diagnosis", section on 'Evaluation and diagnosis' and "Lumbar spinal stenosis: Pathophysiology, clinical
features, and diagnosis", section on 'Diagnosis' and 'Radiculopathy or lumbar spinal stenosis' below.)
Infection — For patients in whom there is a suspicion for spinal infection (including vertebral osteomyelitis or spinal epidural
abscess), the evaluation should be guided by the degree of suspicion ( algorithm 1).
● Moderate to high clinical suspicion for infection – For patients with low back pain in whom there is moderate to high clinical
suspicion for spinal infection, immediate MRI without and with contrast is indicated ( algorithm 1) [73].
Sign and symptoms of infection may include objective fever, tenderness to palpation (vertebral osteomyelitis), and neurologic
symptoms (spinal epidural abscess).
Risk factors for infection include:
• Current immunosuppression
• Current hemodialysis
• Current or recent injection drug use
• Current or recent invasive epidural/spinal procedure
• Current or recent endocarditis or bacteremia
MRI is the most sensitive imaging modality for detecting spinal infection with sensitivity of 0.96 and specificity of 0.92 [19]. For patients
who are unable to obtain an MRI, a CT scan is a useful alternative to evaluate for epidural abscess, while radionuclide scans are an
option to evaluate for osteomyelitis. The evaluation and diagnosis of these conditions are discussed in detail separately. (See "Spinal
epidural abscess", section on 'Diagnosis' and "Spinal epidural abscess" and "Vertebral osteomyelitis and discitis in adults", section on
'Suggested clinical approach' and "Vertebral osteomyelitis and discitis in adults", section on 'Radiographic imaging'.)
● Lower concern for infection – When there is a lower level of concern for the possibility of an infectious cause of back pain, it is
reasonable to first evaluate patients with ESR and/or CRP. Patients with an elevated ESR and/or CRP should be evaluated with MRI (
algorithm 1). (See "Spinal epidural abscess", section on 'Diagnosis' and "Vertebral osteomyelitis and discitis in adults", section on
'Suggested clinical approach'.)
In patients with osteomyelitis or other spinal infection, the sensitivity of an elevated ESR is 0.76 to 0.95 and the sensitivity of an elevated
CRP is 0.82 to 0.98 [3-5]. Infection is very unlikely in patients with an ESR <20 and no more than one risk factor for a systemic illness
[22,45]. (See "Vertebral osteomyelitis and discitis in adults", section on 'Laboratory findings' and "Spinal epidural abscess", section on
'Diagnosis'.)
Cancer — Patients with cancer or risk factors for cancer and neurologic deficits should have immediate imaging as noted above. In
patients without neurologic deficits, the decision to image is based on risk. (See 'Neurologic deficits' above.)
● Current or recent cancer – Imaging for these patients will vary depending on a variety of factors (eg, what the primary cancer is, when
the patient's most recent imaging studies were, whether or not the patient has known bone metastasis). For such patients, we consult
with their oncologist to discuss the most appropriate imaging examination ( algorithm 1). The diagnosis of bone metastasis is
discussed separately. (See "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults", section on 'Overview of the
diagnostic approach'.)
● Moderate to high risk for cancer – In patients at moderate to high risk for cancer, we start the evaluation with plain radiographs and
ESR (or CRP) ( algorithm 1) [18]. Patients with a positive radiograph should have appropriate further evaluation for malignancy (eg,
evaluation for primary site, other metastatic disease). Patients with a positive ESR (or CRP) but negative plain radiograph should be
further evaluated with MRI. (See "Overview of the classification and management of cancers of unknown primary site".)
What constitutes a moderate to high risk for cancer (aside from a history of cancer) is not well-defined and the approach likely differs
among clinicians. Factors to consider include the patient's age, smoking history, family history, physical examination findings, and any
associated concerning symptoms (eg, recent weight loss). Vertebral metastases are often associated with localized pain and focal
tenderness on examination. It is likely that patients having more than one such finding or feature are at higher risk than those with a
single risk factor.
The sensitivity of plain radiographs for malignancy is 0.60 and specificity 0.95 [19]. The yield of plain radiographs is increased when
combined with the ESR [22]. Cancer is very unlikely in a patients with an ESR <20 and no more than one risk factor ( table 9) [22,45].
● Low risk for cancer – We do not obtain immediate imaging in patients with acute back pain who are at low risk for cancer (eg, one risk
factor). If the pain is persistent, we image after four to six weeks. (See 'Cancer risk' below.)
Compression fracture — Patients with suspected vertebral compression fracture should have plain radiographs for evaluation (
algorithm 1). Features in the history that indicate an increased risk for vertebral fractures include prolonged glucocorticoid use, advanced
age, significant trauma or presence of contusion or abrasion, or recent mild trauma in a patient with a known diagnosis of or risk factors for
osteoporosis ( table 3) [72,81,83,84]. Patients can have osteoporotic vertebral compression fractures in the absence of trauma.
Symptomatic patients with osteoporotic fractures typically describe a sudden onset of pain and have localized pain and tenderness on
examination. While the American College of Physicians (ACP) guidelines suggest that imaging should be deferred in patients with suspected
vertebral compression fracture, when clinical suspicion is high it is reasonable to obtain plain radiographs on initial evaluation in order to
institute appropriate symptomatic and preventive therapies. The diagnosis and management of osteoporotic vertebral compression
fractures is discussed in detail separately. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and
treatment", section on 'Diagnosis'.)
Minor trauma — Indications for imaging in patients with trauma are discussed in detail elsewhere. (See "Evaluation of thoracic and
lumbar spinal column injury", section on 'Decision rules for imaging thoracic or lumbar spine injury'.)
Risk assessment subacute back pain — Patients who have not improved after four to six weeks of conservative therapy and who did
not receive imaging on initial evaluation are reevaluated. Patients who have developed neurologic deficits or symptoms of infection in the
interim should have imaging as noted above. (See 'Neurologic deficits' above and 'Infection' above.)
Patients who present initially with low back pain of more than four to six weeks duration should undergo the initial risk assessment as
presented above. (See 'Indications for imaging' above.)
In patients who had indications for immediate imaging and had negative findings, we do not repeat imaging in patients if symptoms are
unchanged [18]. Repeat imaging is indicated in patients with new or worsening symptoms or new concerns that develop in the interim. The
modality will depend upon the suspected diagnosis and the modality of the initial imaging exam.
Radiculopathy or lumbar spinal stenosis — Patients with persistent symptoms due to a lumbosacral radiculopathy or spinal stenosis
who have not responded to conservative treatment and who are candidates for and interested in invasive therapies (eg, surgery or epidural
injection for radiculopathy) should have an MRI for further evaluation and be referred for consideration for these therapies [18]. (See
"Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Neuroimaging' and "Acute lumbosacral
radiculopathy: Treatment and prognosis", section on 'When neuroimaging is diagnostic' and "Lumbar spinal stenosis: Treatment and
prognosis", section on 'Surgical treatment' and "Acute lumbosacral radiculopathy: Treatment and prognosis".)
Cancer risk — In patients with low back pain who did not meet criteria for immediate imaging but who have risk factors for cancer
and do not improve with conservative therapy after four to six weeks, we evaluate with plain radiographs and ESR (or CRP) [18]. Patients
with a positive radiograph should have appropriate further evaluation for malignancy (eg, evaluation for primary site, other metastatic
disease). Patients with a positive ESR (or CRP) but negative plain radiograph should be further evaluated with MRI. (See 'Cancer' above.)
Other patients
● Concern for ankylosing spondylitis – Patients with persistent back pain despite four to six weeks of conservative therapy who also
have signs or symptoms concerning for ankylosing spondylitis should have a plain radiograph to evaluate the sacroiliac joints [18].
These can often be well-evaluated on a lumbosacral plain radiograph. (See "Diagnosis and differential diagnosis of axial
spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'Diagnostic approach'.)
● Concern for osteoarthritis – Lumbosacral, pelvic, and/or hip radiographs may be considered for older patients with persistent back
pain in whom there is concern for osteoarthritis of the hip referred to the back or for whom the mechanical adaptions to hip
osteoarthritis are causing back pain. If a patient's low back symptoms do not lateralize, a standing pelvis radiograph will evaluate both
hips for the presence of osteoarthritis; if symptoms lateralize, a two-view hip (standing frontal and frog-leg views) is appropriate. The
diagnosis and management of osteoarthritis is discussed in detail separately. (See "Clinical manifestations and diagnosis of
osteoarthritis", section on 'Imaging' and "Overview of the management of osteoarthritis".)
● Patients without specific concerns – In other patients where there are no concerns for a particular etiology, we generally treat with
conservative therapy for another eight weeks.
Risk assessment chronic back pain — Patients who present initially with low back pain >12 weeks duration should undergo the risk
assessment for acute and subacute back pain. (See 'Risk assessment for acute back pain' above and 'Risk assessment subacute back pain'
above.)
In patients without specific concerns who have not received any imaging for indications noted above, if there is no improvement after 12
weeks, we generally image with a plain radiograph and consider the need for referrals for further evaluation and treatment.
Counseling patients who request imaging — Patients often expect that imaging will be ordered during their initial visit for back pain.
Although it is not possible to provide a definitive physiologic diagnosis for low back pain in the majority of patients, clinicians can reassure
patients without concerning history or physical examination findings that they appear to have "mechanical" or nonspecific low back pain,
and that it is very unlikely that they have a serious underlying problem. Patients should be assured that improvement is to be expected and
should be advised that:
● They are unlikely to have a serious underlying condition. (See 'Etiologies' above.)
● Incidental imaging findings, unrelated to their pain, are common, and may lead to unnecessary further tests or interventions. (See
'Limited utility of imaging' above.)
● Imaging is appropriate if they do not improve as expected. (See 'Risk assessment subacute back pain' above and 'Risk assessment
chronic back pain' above.)
In addition, a careful physical examination with ongoing commentary ("I am checking strength for any sign of nerve injury") may be
reassuring for patients and help make it clear that the clinician is not inappropriately bypassing a further diagnostic evaluation or
dismissing the symptoms.
Patients who perceive that they have received an adequate explanation for the cause of their problem are less likely to want additional
diagnostic tests and more likely to be satisfied with the visit than those who do not think they have been given an adequate explanation
[85]. In one randomized trial, low-risk patients who received an educational intervention rather than a plain radiograph were equally
satisfied with their care and had equally good clinical outcomes [86].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Lower spine disorders".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Low back pain in adults (The Basics)" and "Patient education: Spinal stenosis (The Basics)" and
"Patient education: Herniated disc (The Basics)" and "Patient education: Muscle strain (The Basics)" and "Patient education: Do I need an
X-ray (or other test) for low back pain? (The Basics)")
● Beyond the Basics topics (see "Patient education: Low back pain in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Most patients who present with back pain to primary care settings will have nonspecific back pain. Such patients will typically improve
over a few to several weeks with conservative or self-care. (See 'Etiologies' above.)
Less than 1 percent will have serious systemic etiologies (eg, malignancy or infection). Less than 10 percent will have less serious,
specific etiologies (eg, vertebral compression fracture, radiculopathy, or spinal stenosis). (See 'Etiologies' above.)
● A focused history and physical examination are sufficient to evaluate most patients with back pain of less than four weeks duration. The
history and physical examination should identify features that suggest that imaging and/or other evaluations are indicated. (See
'History' above and 'Physical examination' above.)
● The majority of patients with low back pain of less than four weeks duration do not require imaging. Among patients seen in primary
care, less than 1 percent will require immediate advanced imaging (eg, magnetic resonance imaging [MRI] or computed tomography
[CT]) ( algorithm 1). (See 'Indications for imaging' above.)
• Any patient with symptoms of spinal cord or cauda equina compression or progressive and/or severe neurologic deficits should
have immediate lumbar spine MRI for further evaluation and urgent specialist referral. Such symptoms and signs include new
urinary retention, incontinence from bladder overflow, new fecal incontinence, saddle anesthesia, and significant motor deficits not
localized to a single nerve root. (See 'Neurologic deficits' above.)
• Other patients who may require imaging on initial evaluation include those with a moderate to high suspicion for spinal infection,
risk factors for metastatic cancer, and suspected vertebral compression fracture. (See 'Risk assessment for acute back pain' above.)
● Patients who have not improved after four to six weeks of conservative therapy and who did not receive imaging on initial evaluation
are reevaluated:
• Patients with persistent symptoms due to a lumbosacral radiculopathy or spinal stenosis who are candidates for and are interested
in invasive therapies (eg, surgery or epidural injection for radiculopathy) should have a lumbar spine MRI for further evaluation.
(See 'Radiculopathy or lumbar spinal stenosis' above.)
• In patients with low back pain who have risk factors for cancer, we evaluate with erythrocyte sedimentation rate (ESR) or C-reactive
protein (CRP) and plain radiographs. (See 'Cancer risk' above.)
• Other patients that may need imaging include those with concerns for ankylosing spondylitis and osteoarthritis. (See 'Other
patients' above.)
• In other patients where there are no concerns for a particular etiology, we generally treat with conservative therapy for another
eight weeks.
● For patients without concerns for a particular etiology who have not improved after 12 weeks total, we generally image with a plain
radiograph and consider referrals for further evaluation and treatment. (See 'Risk assessment chronic back pain' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 7782 Version 80.0
GRAPHICS
Terminology used in spine disc pathology and back pain [1]
Spondylosis: Arthritis of the spine. Seen radiographically as disc space narrowing and arthritic changes of the facet joint.
Anterolisthesis, spondylolisthesis, retrolisthesis:
Anterolisthesis is the anterior displacement of a vertebral body relative to the one below.
Spondylolisthesis is anterolisthesis secondary to spondylolysis but is also used to denote anterolisthesis from any cause.
Retrolisthesis is the posterior displacement of a vertebral body relative to the one below.
A radiologist determines the degree of slippage upon reviewing spinal radiographs. Slippage is graded I through IV:
Grade I - 1 to 25% slip
Grade II - 26 to 50% slip
Grade III - 51 to 75% slip
Grade IV - 76 to 100% slip
Generally, Grade I and Grade II slips do not require surgical treatment and are treated medically. However, Grade III and Grade IV slips, and some milder grade slips, may benefit from surgery if
persistent and disabling symptoms are present.
Spondylolysis:A fracture in the pars interarticularis where the vertebral body and the posterior elements protecting the nerves are joined. In a small percent of the adult population, there is a
developmental crack in one of the vertebrae, usually at L5.
Spinal stenosis: Local, segmental, or generalized narrowing of the vertebral canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the
ligamentum flavum.
Radiculopathy: Impairment of a nerve root, usually causing radiating pain, numbness, tingling, or muscle weakness that corresponds to a specific nerve root.
Sciatica: Pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle.
Cauda equina syndrome: Loss of bowel and bladder control and numbness in the groin and saddle area of the perineum, associated with weakness of the lower extremities. This condition can be
caused by abnormal pressure on the bottom-most portion of the spinal canal and spinal nerve roots, related to either bony stenosis or a large herniated disc.
Lordosis, kyphosis, scoliosis:
Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs).
Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks).
Scoliotic curving is a sideways curvature of the spine and is always abnormal.
A small degree of both kyphotic and lordotic curvature is normal. Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease).
Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent.
Reference:
1. Fardon DF, Williams AL, Dohring EJ, et al. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology
and the American Society of Neuroradiology. Spine J 2014: 14:2525.
Graphic 78051 Version 9.0
Differential diagnosis of low back pain
Mechanical low back pain Nonmechanical spine disease Visceral disease
Lumbar strain Neoplasia Pelvic organs
Degenerative disease Multiple myeloma Prostatitis
Discs (spondylosis) Metastatic carcinoma Endometriosis
Facet joints (osteoarthritis) Lymphoma and leukemia Chronic pelvic inflammatory disease
Spinal cord tumors
Spondylolisthesis Renal disease
Retroperitoneal tumors
Nephrolithiasis
Herniated disc
Infection Pyelonephritis
Spinal stenosis Osteomyelitis Perinephric abscess
Osteoporosis Septic discitis
Aortic aneurysm
Fractures Paraspinous abscess
Gastrointestinal disease
Epidural abscess
Congenital disease Pancreatitis
Severe kyphosis Inflammatory arthritis (often HLA-B27-associated) Cholecystitis
Severe scoliosis Ankylosing spondylitis
Penetrating ulcer
Possible type II or type IV transitional vertebra* Psoriatic spondylitis
Fat herniation of lumbar space
Reactive arthritis
Possible spondylolysis
Inflammatory bowel disease
Possible facet joint asymmetry
Scheuermann disease (osteochondrosis)
Paget disease
HLA: human leukocyte antigen.

* A transitional vertebra is a congenital anomaly in which there is a naturally occurring articulation or bony fusion between the transverse processes of L5 and the sacrum, but there is still a small
remnant disc space between L5 and the sacrum. Type II means that one or both transverse processes appear to form a diarthrodial joint with the sacrum, but there is no bony fusion. Type IV means that
there is a type II abnormality on one side and a complete bony fusion on the opposite side.
Reproduced from: Deyo RA. Early diagnostic evaluation of low back pain. J Gen Intern Med 1986; 1:328, with kind permission from Springer Science + Business Media B.V. Copyright © 1986.
Clinical risk factors for fracture
Advancing age
Previous fracture
Glucocorticoid therapy
Parental history of hip fracture
Low body weight
Current cigarette smoking
Excessive alcohol consumption
Rheumatoid arthritis
Secondary osteoporosis (eg, hypogonadism or premature menopause, malabsorption, chronic liver disease, inflammatory bowel disease)
Data from: Kanis JA, Borgstrom F, De Laet C, et al. Assessment of fracture risk. Osteoporos Int 2005; 16:581.
Solitary nerve root lesions of the lumbosacral spine
Root Pain Sensory loss Weakness Stretch reflex loss
L1 Inguinal region Inguinal region Rarely hip flexion None
L2-L3- Back, radiating into anterior thigh, and at times Anterior thigh, occasionally medial Hip flexion, hip adduction, knee extension Patellar tendon
L4 medial lower leg lower leg
L5 Back, radiating into buttock, lateral thigh, lateral Lateral calf, dorsum foot, web space Hip abduction, knee flexion, foot dorsiflexion, toe Semitendinosus/semimembranosus
calf and dorsum foot, great toe between first and second toe extension and flexion, foot inversion and eversion (internal hamstrings) tendon
S1 Back, radiating into buttock, lateral or posterior Posterior calf, lateral or plantar Hip extension, knee flexion, plantar flexion of the foot Achilles tendon
thigh, posterior calf, lateral or plantar foot aspect of foot
S2-S3- Sacral or buttock pain radiating into the posterior Medial buttock, perineal, and Weakness may be minimal, with urinary and fecal Bulbocavernosus, anal wink
S4 aspect of the leg or the perineum perianal regions incontinence as well as sexual dysfunction
Testing for lumbar nerve root compromise
Data from: Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice
Guideline, Quick Reference Guide Number. 14. Rockville, MD: U.S. Department of Health and
Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub.
No. 95-0643. December 1994.
Common pathoanatomical conditions of the lumbar spine
(A) A superior view of a normal lumbar vertebra with cauda equina, nerve roots, intervertebral disc and
ligamentum flavum.
(B) A superior view demonstrating abnormalities including a thickened ligamentum flavum, a
hypertrophied facet and a herniated disc. These pathologic structures cause the canal to narrow and
can impinge on the cauda equina and nerve roots.
(C) A lateral view of the lumbosacral spine demonstrating spondylolysis and spondylolisthesis.
Spondylolysis is a fracture in the pars interarticularis of the vertebra. Spondylolisthesis occurs when this
fracture widens and the vertebral body slides forward on the one below it.
Comparison of symptoms in neurogenic and vascular claudication
Symptoms Neurogenic Vascular
Quality Pain/numbness/tingling/weakness Pain/cramping/tightness
Increased with walking Yes Yes
Relieved walking flexed with a cart Yes No
Relieved standing erect No Yes
Relieved sitting/lying Within minutes Immediate
Increased walking uphill/upstairs No/less Yes
Increased walking downhill Yes/more Yes
Increased biking/back flexed No Yes
Increased biking/back extended Yes Yes
Clinical manifestations of osteoarthritis
Age of onset
Usually after age 40
Commonly affected joints

Cervical and lumbar spine
First carpometacarpal joint
Proximal interphalangeal joint
Distal interphalangeal joint
Hip
Knee
Subtalar joint
First metatarsophalangeal joint
Uncommonly affected joints

Shoulder
Wrist
Elbow
Metacarpophalangeal joint
Symptoms
Pain without significant swelling or other inflammatory characteristics
Stiffness, if present, worse after effort; may be described as evening stiffness
Findings on physical examination

Crepitus
Bony enlargement
Decreased range of motion
Malalignment
Tenderness to palpation
Synovial fluid analysis

Clear fluid
WBC <2000/mm 3
Normal viscosity
Radiographic features
Joint space narrowing
Subchondral sclerosis
Marginal osteophytes
Subchondral cysts
Patterns of presentation
Monoarticular in young adult
Pauciarticular, large-joint in middle age
Polyarticular generalized
Rapidly progressive
Secondary to trauma, congenital abnormality, or systemic disease
Prognosis
Variable, generally slowly progressive
WBC: white blood cells.
Nonorganic signs in low back pain (originally described by Waddell)
Overreaction during physical examination
Superficial or widespread tenderness
Inconsistent supine and seated (distracted) straight leg raise test
Unexplainable neurologic deficits
Pain on simulated axial load (top of head pressure)
Schmorl's nodes
Schmorl's nodes. Sagittal image from a spine MRI shows intraverebral disc herniation
(arrows).
MRI: magnetic resonance imaging.
Courtesy of Jeﬀrey Jarvik, MD, MPH.
American College of Physicians best practice advice: Diagnostic imaging for low back pain
Diagnostic imaging techniques Radiography
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Indications for diagnostic Radiography is recommended in patients with acute low back pain who have major risk factors for cancer (new onset of low back pain with history of cancer,
imaging multiple risk factors for cancer, or strong clinical suspicion for cancer).
MRI is recommended in patients with acute low back pain who have risk factors for spinal infection (new onset of low back pain with fever and history of
intravenous drug use or recent infection), risk factors for or signs of the cauda equina syndrome (new urinary retention, fecal incontinence, or saddle anesthesia),
or severe or progressive neurologic deficits.
Radiography is recommended after a trial of therapy in patients with minor risk factors for cancer (unexplained weight loss or age >50 years), risk factors for
ankylosing spondylitis (morning stiffness that improves with exercise, alternating buttock pain, awakening because of back pain during the second part of the
night), risk factors for vertebral compression fracture (history of osteoporosis, glucocorticoid use, significant trauma, or older age [>65 years for men or >75 years
for women]).
MRI is recommended after a trial of therapy in patients with signs/symptoms of radiculopathy (back pain with leg pain in an L4, L5, or S1 nerve root distribution
or positive result on straight leg raise or crossed straight leg raise test) who are candidates for surgery or epidural steroid injection. MRI is also recommended in
patients with risk factors for or symptoms of symptomatic spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for
surgery.
MRI is generally preferred over CT scan for most cases of low back pain. CT scan may help visualize bony abnormalities and is used when patients have a
magnetic implant that is not suitable for MRI.
Repeated imaging is only recommended in patients with new or changed low back symptoms.
Evidence that expanding Randomized trials of routine imaging versus usual care without routine imaging in patients without indications for diagnostic imaging suggest no clinically
imaging to patients without meaningful benefits on outcomes related to pain, function, quality of life, or mental health.
these indications does not
Other supporting evidence includes the weak correlation between most imaging findings and symptoms, the favorable natural history of acute low back pain
improve outcomes
with or without imaging, the low prevalence of serious or specific underlying conditions, and unclear effects of imaging on treatment decisions.
Harms of unnecessary imaging Radiation exposure (for lumbar radiography and CT)
Labeling
Hypersensitivity reactions and contrast nephropathy (for iodinated contrast with CT)
Potential association with subsequent unnecessary, invasive, and expensive procedures
Approaches to overcome Patient expectations or preferences for routine imaging: Use talking points based on evidence-based guidelines to aid in patient education
barriers to evidence-based
Time constraints: Use evidence-based online or print education material to supplement face-to-face education
practice
Clinician uncertainty: Recognize the low likelihood of serious conditions in the absence of clinical risk factors and the evidence that shows no benefit associated
with routine imaging
Clinician incentives based on patient satisfaction: Advocate for incentives that are based on providing appropriate care
Talking points for clinicians Risk factor assessment can almost always identify patients who require imaging
when discussing low back pain
The prevalence of serious underlying conditions is low in patients without risk factors
imaging with patients
The natural history of acute low back pain is quite favorable, but patients require reevaluation if they are not better after about one month
Routine imaging does not improve clinical outcomes but increases costs and may lead to potentially unnecessary invasive treatments, such as surgery
Imaging abnormalities are extremely common, especially in older adults, but most are poorly correlated with symptoms
In most cases, treatment plans do not change after imaging studies
Back imaging is associated with radiation exposure, which can increase the risk for cancer in the case of lumbar radiography and CT
Modiﬁed and reproduced with permission from: Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med
2011; 154:181. Copyright © 2011 American College of Physicians.
Acute low back pain: Considerations for imaging
MRI: magnetic resonance imaging; MM: multiple myeloma; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; CT: computed tomography.
* Lumbar spine MRI without contrast is usually appropriate. If there is concern for cancer or infection or if there is history of prior surgery at the site, MRI without and with contrast is recommended. CT with
contrast is the alternative exam if MRI is contraindicated.
Diagnostic tests for cancer as cause of low back pain
Sensitivity Specificity
Erythrocyte sedimentation rate

≥20 mm/hour 0.78 0.67
≥50 mm/hour 0.56 0.97
≥100 mm/hour 0.22 0.996
Anemia (hematocrit <40 percent for men or <38 percent for women) 0.54 0.86
Hematocrit <30 0.09 0.994
White blood cell count ≥12,000 0.22 0.94
WBC: White blood cell count.
Data from: Deyo, RA, Diehl, AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Int Med 1988; 3:230.
Contributor Disclosures
Stephanie G Wheeler, MD Nothing to disclose Joyce E Wipf, MD Nothing to disclose Thomas O Staiger, MD Nothing to disclose Richard A Deyo, MD,
MPH Nothing to disclose Jeffrey G Jarvik, MD, MPH Equity Ownership/Stock Options: Physiosonics [HIFU]. Other Financial Interest: GE Healthcare [Travel
reimbursement]. Steven J Atlas, MD, MPH Equity Ownership/Stock Options: Stryker Corp. Grant/Research/Clinical Trial Support: Bristol Myer Squibb/Pfizer
Alliance [Atrial fibrillation]. Lisa Kunins, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors
and must conform to UpToDate standards of evidence.
Conflict of interest policy

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● In subsequent observational studies:

Risk factors for infection include:

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

[CT]) ( algorithm 1). (See 'Indications for imaging' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 7782 Version 80.0

Anterolisthesis, spondylolisthesis, retrolisthesis:

Grade I - 1 to 25% slip

Grade II - 26 to 50% slip

Grade III - 51 to 75% slip

Grade IV - 76 to 100% slip

Lordosis, kyphosis, scoliosis:

Scoliotic curving is a sideways curvature of the spine and is always abnormal.

Graphic 78051 Version 9.0

Differential diagnosis of low back pain

Mechanical low back pain Nonmechanical spine disease Visceral disease

Lumbar strain Neoplasia Pelvic organs

Degenerative disease Multiple myeloma Prostatitis

Discs (spondylosis) Metastatic carcinoma Endometriosis

HLA: human leukocyte antigen.

Graphic 60679 Version 11.0

Clinical risk factors for fracture

Parental history of hip fracture

Low body weight

Current cigarette smoking

Excessive alcohol consumption

Graphic 76445 Version 3.0

Solitary nerve root lesions of the lumbosacral spine

Root Pain Sensory loss Weakness Stretch reflex loss

L1 Inguinal region Inguinal region Rarely hip flexion None

Graphic 75645 Version 4.0

Testing for lumbar nerve root compromise

Graphic 68791 Version 7.0

Common pathoanatomical conditions of the lumbar spine

Graphic 74811 Version 5.0

Comparison of symptoms in neurogenic and vascular claudication

Symptoms Neurogenic Vascular

Quality Pain/numbness/tingling/weakness Pain/cramping/tightness

Increased with walking Yes Yes

Relieved walking flexed with a cart Yes No

Relieved standing erect No Yes

Relieved sitting/lying Within minutes Immediate

Increased walking uphill/upstairs No/less Yes

Increased walking downhill Yes/more Yes

Increased biking/back flexed No Yes

Increased biking/back extended Yes Yes

Graphic 80902 Version 3.0

Clinical manifestations of osteoarthritis

Commonly affected joints

First carpometacarpal joint

Proximal interphalangeal joint

Distal interphalangeal joint

First metatarsophalangeal joint

Uncommonly affected joints

Stiffness, if present, worse after effort; may be described as evening stiffness

Findings on physical examination

Decreased range of motion

Synovial fluid analysis