Low back pain (acute)

CHAPTER 21 Low back pain (acute)

A report of acute low back pain (ALBP), although quite common, requires a thorough evaluation. The underlying pathophysiology of back pain is frequently multifactorial and includes both physiological and psychological components. The most common causes of ALBP relate to musculoligamentous injuries and age-related degenerative processes. About 90% of ALBP episodes in adults are related to mechanical causes that resolve within 4 weeks without serious sequelae. A smaller percentage of patients will continue to have chronic symptoms without organic pathology or will have underlying disease.

In children, the prevalence of back pain increases with age and with involvement in sports. Anthropometric variations in children place them at risk for excess strain on the spine, producing back pain. These variations include reduced hip mobility, decreased lumbar extension and increased lumbar flexion, poor abdominal muscle strength, tight hamstring muscles, and lumbar hyperlordosis.

ALBP is defined as activity intolerance producing lower back or back-related leg symptoms of less than 3 months’ duration. The Agency for Healthcare Research and Quality (AHRQ) guidelines provide the following framework for causes of ALBP:

Potentially serious conditions (e.g., spinal fracture, tumor or infection, or cauda equina syndrome)

Sciatica, or leg pain and numbness of the lateral thigh, leg, and foot, suggesting nerve root compression (Figure 21-1)

Nonspecific back problems such as musculoskeletal strain, diskogenic pain, or bony deformity secondary to inflammatory disease

Nonspinal causes secondary to abdominal involvement (e.g., gallbladder, liver, renal, pelvic inflammatory disease; prostate tumor; ovarian cyst; uterine fibroids; aortic aneurysm; or thoracic disease)

Psychological causes such as stress, work environment (e.g., disability, workers’ compensation, secondary gains)

FIGURE 21-1 Testing for lumbar nerve root compromise.

(From Bigos S et al: Acute low back problems in adults, clinical practice guidelines, Quick Reference Guide Number 14, Rockville, MD, 1994, Department of Health and Human Services, U.S. Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 95-0643.)

When evaluating ALBP, the goal of the clinician is to first identify signs and symptoms of potentially serious conditions through a careful history and physical examination. A holistic approach to the patient is needed to appreciate the extent to which pain affects the patient’s daily routine or work-related activities. Because ALBP is a common occupation-related complaint and a cause of disability and lost productivity, the clinician must gain insight into the psychosocial and economic situation of the patient to help arrive at a correct diagnosis.

Diagnostic reasoning: focused history

Is this a potentially serious cause of ALBP?

Key questions

Do you have a fever?

Have you experienced any trauma to the spine or back?

Do you have any other health problems?

Have you been treated for cancer?

What is your age?

Have you had loss of control of your bowels or bladder?

Are you taking any medications?

Fever

The presence of a fever indicates an inflammatory condition such as spondyloarthropathy or systemic infection. Infection is a likely diagnosis when there are chills and fever, weight loss, a recent history of bacterial infection, intravenous drug use, or an immunosuppressed patient. Ewing sarcoma is a malignant tumor and can mimic spinal infection, occurring as back pain that can be accompanied by fever. Children with diskitis will have a fever and refuse to walk because of back pain.

Trauma

Acute trauma to the spinal cord can result in fracture, dislocation, or misalignment of muscles, ligaments, and intervertebral disks. Trauma may be caused by blunt impact, repetitive injury, or sudden stress caused by lifting or pulling. Low back pain is the most common occupational injury reported. Injury to the back usually results in contusions and abrasions but can also cause spinal fracture if the force is major, such as that sustained in a motor vehicle accident or fall. In the elderly, an acute spinal fracture might result from strenuous lifting when osteoporosis is present. Injuries to the posterior structures of the spine account for most cases of low back pain in adolescents who are athletically active.

Injury to the spinal column should be suspected in anyone whose level of consciousness is impaired after an accident. Cervical spine fractures are sustained during flexion, extension, compression, rotation, or a combination of forces.

Age

In the absence of trauma, the sudden onset of severe low or middle back pain in persons older than 30 years might suggest a dissecting aortic aneurysm. The pain will not be alleviated by rest. Patients older than 50 years are at increased risk for compression fracture as well as cancer.

Systemic disease

Metabolic disease, inflammatory disorders, and fibromyalgia can lead to back pain. Patients with a history of cancer may have increased risk of a spinal tumor. Neuroblastoma is common in young children, and although it occurs in the abdomen, metastases to the spine may produce back pain. Systemic disease may also be accompanied by unexplained weight loss. Persons younger than 20 years and older than 50 years are at increased risk for tumor, as are those with a history of cancer.

Bowel and bladder symptoms

Loss of urinary or stool continence indicates cauda equina or S1-S2 nerve root compromise secondary to a herniated disk, nerve root entrapment, spinal stenosis, infection, or tumor. Constant lumbar puncture with saddle anesthesia, urinary retention, and fecal incontinence are symptoms of cauda equina syndrome, which is considered a surgical emergency.

Children are embarrassed to talk about urinary or bowel habits and changes. Hidden spinal cord tumors might have a relationship to developmental delays in bladder and bowel control. Children under 4 years of age who have back pain should be evaluated for serious diseases, such as intraspinal tumors, dermoid cysts, and malignant astrocytomas.

Location of pain

In general, children are less specific than adults when describing location of pain. Traumatic lesions are more likely to occur in the cervical and lumbar portions of the spine, where there is more motion and less protection. Generalized pain or pain over a fairly wide anatomical area is frequently seen with overuse problems and inflammatory conditions.

Sciatica pain is a sharp, burning pain that radiates down the posterior and lateral leg to the foot or ankle. Back pain with neck stiffness can indicate cervical osteomyelitis. Rheumatoid arthritis produces pain in the upper back and neck. Localized pain is seen with spondylolysis and tumors. Flank pain in adults may indicate a kidney infection. Pain of gallbladder disease radiates to the subscapular areas. Compression fractures of vertebrae associated with osteoporosis or malignancy may produce pain over the midthoracic area.

Children with traumatic low back derangement will have pain and muscle spasm in the lumbar area from the pressure and shock of an impact injury collision.

What does the pattern of pain tell me?

Key questions

When did the pain start?

How long have you had this pain?

What does the pain feel like?

Does it interfere with sleep?

Have you had this pain before?

Onset

The onset of ALBP is sudden, and more than half of patients with this symptom do not associate it with a specific precipitating event or injury. The vast majority of cases of ALBP resolve with conservative treatment in 4 weeks, and radiographic or further diagnostic studies are not recommended until then.

Children are frequently poor historians and parents may have a difficult time remembering when the pain started. Association with events such as birthdays, holidays, and activities is helpful in establishing the onset of the pain. Pain that is mild and of short duration (1 to 2 weeks) is rarely serious.

Back pain lasting longer than 4 weeks needs to be reevaluated for further diagnostic studies.

Duration

Subacute back pain is of 6 to 12 weeks’ duration. Chronic back pain is pain of more than 3 months’ duration. In persons under 40 years of age, the cause may be postural or may indicate congenital spinal deformity, such as scoliosis or ankylosing spondylitis. In older persons, chronic back pain is more likely to indicate degenerative disease, such as spinal stenosis or disk herniation. In children, back pain present for more than 3 weeks is often due to organic and serious causes.

Pain characteristics

In children, expression of pain depends on the child’s ability to put feelings of pain into behavior; observing for these behaviors is important. Ask children to rate the pain using a 10-point pain scale with happy to sad faces (see Chapter 2). Ask adults to rate pain from 0 (no pain) to 10 (worst pain ever) and assess how much the pain interferes with daily activities. Intractable back pain, especially night pain with constitutional findings, is likely to indicate neoplastic disease. Painful scoliosis and stiffness are common presenting symptoms of a spinal tumor.

Night pain

Nighttime back pain is a worrisome symptom that often signals a serious problem, such as tumor, infection, or inflammation. Generally, muscle pulls, overuse injuries, spondylolysis, spondylolisthesis, and Scheuermann disease (an exaggeration of the normal posterior convex curvature of the thoracic spine) produce less pain at night. Morning stiffness that improves as the day progresses suggests ankylosing spondylitis.

Nighttime back pain is unusual and indicates the need for a complete and thorough workup.

Aggravating factors

Pain experienced in the lumbar area occurring after strenuous sporting activities is usually the result of trauma to the muscles and tendons, causing contusions and sprain. It occurs when the patient pushes the muscles and ligaments past the normal level of tolerance. Repeated injury can cause soft tissue scarring and shortening.

Stress and fatigue fractures of the pars interarticularis, the region between the superior and inferior articulating facets of the vertebra, occur when lumbar lordosis places more stress on the pars, such as in gymnastics and tennis.

Pain that is aggravated by activity is usually musculoskeletal in origin. Pain of ankylosing spondylitis is relieved with exercise. Spinal stenosis is associated with increased pain with standing, sneezing, or coughing.

Any child who has voluntarily given up a pleasurable activity because of back pain has a severe symptom.

Alleviating factors

Back pain not associated with any activity and not relieved by rest may indicate tumor. Back pain relieved with aspirin or nonsteroidal anti-inflammatory drugs in children may indicate an inflammatory cause. Pain that is alleviated by rest and heat indicates a musculoskeletal cause. Pain of spinal stenosis is relieved on flexion of the spine.

Suspect spondylolisthesis, or forward slippage of one vertebra over another, if the onset of pain is during hyperextension, such as with a back handspring, butterfly stroke in swimming, or a tennis serve. The defect arises from a stress fracture or stress reaction of the isthmus of the pars interarticularis in the area of L5-S1. The pain localizes to the low back and occurs during a growth spurt and after engaging in sporting events. The pain improves with rest and is worse with standing.

What does radiation of pain tell me?

Key questions

Does the pain travel?

Can you show me where the pain travels?

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Tags: Advanced Health Assessment Clinical Diagnosis in Primary Care

Apr 10, 2017 | Posted by admin in NURSING | Comments Off

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