CE/CME

Low Back Pain: Evidence-based Diagnosis and Treatment

Clinician Reviews. 2016 May;26(5):38-45

References

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STRATIFICATION OF LOW BACK PAIN
Koes and colleagues analyzed 13 different national guidelines and two international guidelines for the management of LBP.⁵ They found that the guidelines consistently recommend focusing the history and physical exam (HPE) on identifying features suggestive of underlying serious pathology, or “red flags,” and excluding specific diseases.⁵ They also found that none of the guidelines recommends the routine use of imaging in patients without suspected serious pathology.⁵ The American College of Radiology simplified this approach to patients with LBP by creating a list of red flags to look for during the HPE.³ The presence of red flags indicates a case of complicated LBP, and patients who present with them should undergo additional diagnostic studies to screen for serious underlying conditions (see the Table).

The HPE should ultimately separate patients into three categories to determine the need for imaging (and course of treatment): (1) simple acute back pain, (2) complicated back pain with red flag (ie, a potential underlying systemic disease), and (3) LBP with neurologic deficits potentially requiring surgery.⁵

Simple acute low back pain
Up to 85% of patients presenting with LBP may never receive a definitive diagnosis due to lack of specific symptoms and ambiguous imaging results.⁶Clinicians can assume that LBP in these patients is due to a mechanical cause, by far the most common cause of LBP.⁷ It is therefore more useful to rule out serious or potentially fatal causes of LBP (complicated LBP) rather than rule in a cause for patients presenting with LBP.

It is generally accepted among practitioners that a thorough HPE alone is sufficient for evaluating most patients presenting with acute LBP lasting less than four weeks.⁵ Patients presenting without red flags should be assured that improvement of acute LBP is typical, and that no diagnostic intervention is needed unless they do not improve as expected per patient or provider (eg, in terms of activities of daily living or work restrictions). The Figure depicts an appropriate approach to diagnosis and treatment in patients presenting with LBP.⁸ Clinicians should also offer patient education for self-care and discuss noninvasive treatment options, including pharmacologic and nonpharmacologic therapy.⁹

Low back pain with red flags (complicated)
Patient history is more useful than the physical exam in screening for spinal malignancies. In one particular combination (age > 50, history of cancer, unexplained weight loss, and failure to improve with conservative therapy), red flag symptoms are 100% sensitive for detecting malignancy.¹⁰ However, malignant neoplasms of the spine make up less than 1% of the diagnoses of patients presenting with LBP in primary care.⁴ Additionally, Deyo and Diehl reviewed five studies of a large series of consecutive spine films with large sample sizes and found the incidence of tumors, infections, and inflammatory spondyloarthropathies together were present in less than 2%.¹¹ This low prevalence underscores the challenge of diagnosing serious pathology of the spine in the primary care setting.

Patients with complicated back pain presenting with red flags should always be examined for an underlying systemic disease. There is one red flag that, seen in isolation, meaningfully increases the likelihood of cancer: a previous history of cancer.⁴ Otherwise, inflammatory markers (eg, erythrocyte sedimentation rate) can be used to determine the need for advanced imaging (see the Figure).¹⁰

Low back pain with neurologic findings (sciatica)
Screening (HPE) for neurologic damage is difficult because traditional findings of neurologic injury (paresis or muscle weakness, impaired reflexes, sensory deficits, and decreased range of motion) all have low sensitivity with higher specificity.¹² For this reason, these tests are of limited value as screening tools during the HPE. Specific exams, such as the straight leg raise and crossed straight leg tests, are also of limited value, especially in the primary care setting, because of inconsistent sensitivity and specificity.

This is the primary reason that the HPE in patients with LBP who have neurologic findings must include evaluation for urgent findings (see the Figure). If any red flags are present, advanced imaging is immediately warranted. Otherwise, inflammatory markers and plain radiography may be obtained, and advanced imaging may be considered if the plain radiography and/or inflammatory markers are abnormal.

There is also an approach that advocates the use of advanced imaging in patients with significant functional disability due to their LBP. Two questionnaires, the Oswestry Low Back Pain Disability Index and the Roland-Morris Disability Questionnaire, evaluate subjective data to determine a patient’s functional disability due to LBP.The validity of both tests has been confirmed.¹³

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Low Back Pain: Evidence-based Diagnosis and Treatment

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