Low back pain differentiation

Ø Symptom, not disease

Ø Defined as pain in the back from the level of the lowest rib down to the gluteal fold, w/h or w/o radiation to the legs
Ø Episode of low back pain: acute if it’s the first time/after a pain free interval of at least 6months & last no longer than 6 weeks
Ø Diagnosis:

Adult patient
with LBP
symptoms

History and
physical
examination

Exclude non
spinal causes of
Diagnostic LBP
Triage

2. Radicular
1. Specific spinal 3. Non specific
syndrome (5-
pathology (<1%) LBP (90-95%)
10%)
Basic clinical examination:
Ø Inspection: general condition, gait, asymmetry (muscle atrophy), deformities, skin changes
Ø Palpation of local musculature (tone, tenderness)
Ø Pain on palpation & percussion of spinal structures, esp. spinous process (fracture) & kidneys
Ø Range of motion of the lumbar spine & hip joints
Ø Nerve-stretching tests, esp. Lasegue & femoral nerve stretch test
Ø General testing of sensation, motor function & reflexes (hyperesthesia, allodynia, strength grading, reflexes)

Examination:
Nerve Compression Levels and Exam Findings:
Ø L4 Level -- Inversion of foot, knee jerk, medial foot sensation.
Ø L5 Level -- EHL dorsiflexion, No reflex loss, dorsal foot sensation.
Ø S1 Level -- Eversion of the foot, ankle jerk and lateral foot sensation

Lab tests:
CBC, CRP/ESR  tumor/infection

X-Ray:
Spurs, Narrow joint space, Marginal sclerosis

Indications for CT, MRI:

Ø Red flags for infection, fracture, tumor, cauda equina syndrome:
 >50 y.o.
 History of malignancy
 Fever/weight loss/elevated ESR
 Trauma
 Motor deficit
 Steroid use
 Drug abuse
Ø Symptoms >1 month & surgery being considered
Ø Prior back surgery