Low back pain

EBM Guidelines
18.9.2019

Essentials

  • Sufficient time for the survey of the history and for the physical examination of the patient
  • Early recognition of serious causes of back pain and of nerve root compression
  • Organization of further investigations and treatment without delay in situations where conservative treatment may lead to complications (cauda equina, severe functional disorders of nerves, and other critical "red flag" situations). In such situations the treatment should be organized in a unit capable of urgent MRI and other investigations.
  • Adequate treatment of pain: according to the intensity of pain the choice is paracetamol, a NSAID or a combination of a NSAID and a mild opioid analgesic
  • Avoidance of bed rest
  • Continuation or resumption of ordinary daily activities as soon as possible
  • Provision of adequate and truthful patient information on the general development of the disease that often has a good prognosis: the pain will usually resolve but has a tendency to recur
  • Follow-up of the patient and restoration of his/her functional capacity
  • In prolonged low back pain or if the symptom picture becomes worse during the weeks to come, reassess the diagnosis and line of treatment.
  • Unless a clear disease that requires spezialiced care can be established, treatment consists of multidisciplinary and active rehabilitation as well as assessment of the patient’s psychosocial situation
  • In chronic low back pain that has lasted for more than 3 months: intensive multidisciplinary rehabilitation

Epidemiology

  • Low back pain is a very common condition: nearly 80% of people experience a disabling low back pain at some point in their lives.
  • Of all patients in general practice 4–6% of working age women and 5–7% of working age men present with low back pain as their main complaint.
  • It is estimated that 15% to 20% of adults have back pain during a single year and 50% to 80% experience at least one episode of back pain during a lifetime. At any one time, about 15% of adults have low back pain.

Clinical examination

History

  • Taking a history is the most important part in the clinical examination of a back pain patient. Data obtained from the history can be classified as follows:
    • Earlier low back pain (onset of symptoms, visits at a doctor, earlier investigations, treatments and sick leaves)
    • Current low back pain (onset, nature and intensity of symptoms, pain and sensory disturbances in the lower extremity, perceived disability in daily living, investigations, treatments and their effectiveness)
    • Other illnesses (operations, traumas, other musculoskeletal disorders, other diseases such as diabetes and arteriosclerosis in lower extremities, diseases of the urogenital system, allergies, current medication)
    • Social history (couple relationship, family, education)
    • Lifestyle (physical exercise, leisure time activities, smoking, use of alcohol and drugs, diet)

Physical examination

  • In the physical examination, emphasis is placed on the detection of possible serious disease and signs of nerve root compression as well as on the assessment of functional capacity. The patient should undress to a sufficient degree.
  1. Inspection of the spine
    • Flattening of lordosis or scoliosis due to acute pain
    • Bending of the lumbar spine; painful restriction may indicate the degree of severity.
  2. Examination of the mobility of the back
    • Restriction in bending forward, backward and sideways may give a picture of the severity of the back pain.
    • Mobility of the spine and disturbances in the rhythm of motion provide understanding of the functional capacity of the back, and measuring the mobility is of significance in follow-up of the condition.
    • The adjusted Schober test has moderate repeatability in measuring the mobility.
    • The rotational motion of the spine and the mobility of the thorax become early restricted in ankylosing spondylitis «Ankylosing spondylitis and axial spondyloarthritis»1.
  3. Assessment of signs of nerve root compression
    • Straight leg raising (SLR) and Lasègue's test are sensitive but non-specific tests for verifying nerve root compression at S1 and L5 level.
      • The tests are interpreted as positive when they cause pain radiating from the back to the lower limb. Back pain itself or tightness behind the knee are not positive signs.
      • In nerve root compression, passive dorsiflexion of the foot during SLR test increases the pain radiating from the back to the limb.
      • Crossing pain: Intensified radiating pain when raising the contralateral limb is a specific sign of nerve root compression.
    • Muscular strength of the lower limbs
      • Knee extension (L4 and partially L3 nerve root)
      • Dorsiflexion of the ankle (L5, partially L4 nerve root), dorsiflexion of the big toe (L5 root) and plantar flexion of the ankle (S1 nerve root)
      • Walking on heels (L5, partially L4 nerve root) or on toes (S1 root)
    • Tendon reflexes
      • Patella (L4 nerve root)
      • Achilles (S1 nerve root)
      • Babinski (upper motor neuron)
    • Patients with lower limb symptoms are examined for sense of touch on the lower medial side of the knee (L4 nerve root), medial (L5 nerve root), dorsal (L5 nerve root) and lateral (S1 nerve root) sides of the foot.
    • Decreased muscle strength of both legs (paraparesis), enhanced or multiple tendon reflexes, and a positive Babinski's sign suggest a need for neurological or neurosurgical assessment. Paraparesis is an indication for immediate referral to a hospital with a possibility to urgently carry out an MRI examination and to perform potential surgery.
    • Rectal touch (tonus of the sphincter) and the sense of touch of the perineum should be examined when cauda equina syndrome is suspected (immediate referral).
  4. Palpation of the vertebrae, sciatic nerves and lower extremities
    • Numerous tender points and associate symptoms may suggest e.g. fibromyalgia «Fibromyalgia»2.
    • Palpation or Doppler ultrasonography, or both, of the arteries in the lower extremities in patients over 50 years of age with intermittent claudication «Lower limb ischaemia»3

Psychosocial risk factors

Table 1. Factors suggesting an increased risk for chronicity of back pain
Belief that pain and physical activity are harmful
Inappropriate illness behaviour (e.g. prolonged bed rest)
Depressed mood, negativity and social withdrawal
Seeking for many different therapies
Physically strenuous work
Problems at the workplace and dissatisfaction with the work
Overprotective family or lack of support
Complaints, litigations and compensation claims

Classification of diagnostic urgency

  • Uncommon but serious causes of back pain should be recognized at an early stage. Also, signs of sciatic syndrome should be recognized.
  • Back symptoms can be divided into 3 categories on the basis of the history and the findings in clinical examination.
    1. Possible serious (tumour, infection, fracture, cauda equina syndrome, or disc herniation/spinal stenosis that causes another type of serious innervation disturbance) or specific disease (ankylosing spondylitis); see table «The most common serious or specific causes for low back pain and urgency of referral»2
    2. Symptoms in the lower limbs suggesting nerve root dysfunction (sciatic syndrome, intermittent claudication)
    3. Non-specific back pain: symptoms occurring mainly in the back without any suggestion of nerve root involvement or serious disease.
Table 2. The most common serious or specific causes for low back pain and urgency of referral
DiseaseHistory, symptoms and signsUrgency of referral to specialized care; see also indications for surgery «»1
Disc herniation, spinal stenosis associated with cauda equina syndrome, excruciating pain and a fresh paresis of one of the muscle groups of the lower extremity Difficulty initiating urination, urinary retention or incontinence, anal incontinence, perineal anaesthesia (saddle sensory loss), usually symptoms of lower limb paralysis and a clear sensory disturbanceImmediate referral to a unit with possibility to carry out immediate imaging and surgery
Ruptured aortic aneurysm, acute aortic dissecationSudden, excruciating pain, age above 50 years, instable haemodynamicsImmediate referral to a unit with possibility to carry out immediate imaging and surgery
Malignant tumourAge above 50 years, history of cancer, involuntary weight loss, recurrent febrile episodes, progressive symptoms, pain at rest, duration of pain for over one month, paraparesisUrgent referral; immediate referral in paraparesis
Bacterial spondylitisPrevious back operation, urinary tract or skin infection, immunosuppression, glucocorticoid medication, abuse of intravenous drugsImmediate referral
Compression fracture of the spine «Significant trauma, or falls among elderly, older age and corticosteroid use appear to be proper red flags for vertebral fracture in patients presenting with low back pain.»B, sacral fractureAge above 70 years, history of falling, peroral glucocorticoid medicationImmediate referral if paresis is present, otherwise referral by appointment
SpondylolisthesisAdolescent (age 8–15 years)Referral by appointment
Spinal stenosisAge above 50 years, neurogenic claudicationReferral by appointment
Ankylosing spondylitisAge below 40 years at the onset of symptoms, pain is not alleviated by bed rest, morning stiffness, duration at least 3 monthsReferral by appointment

Serious or specific diseases

  • Immediate referral
    • Urination is not possible or there is faecal incontinence (disturbance of sphincter function).
    • The patient has excruciating pain and a developing or complete fresh paresis of some muscle group.
    • Progressive proximal sensory disturbance that extends close to the cauda region, often also motor weakness (careful examination is necessary).
    • In addition to the low back pain, the patient has symptoms or clinical signs suggesting an acute severe abdominal emergency.
  • Refer to investigations in specialized care that should take place within the next few days or, the latest, within a week
    • Partial weakness, sensory loss or numbness appears in the lower extremities.
    • General condition is deteriorating or pain is gradually growing more severe.
    • Back pain is not alleviated by medication at rest.
    • Back pain is associated with fever.

Laboratory tests

  • Laboratory tests are usually not needed. If there are signs of a serious or specific disease, the basic laboratory tests usually needed include at least ESR, CRP, basic blood count with platelets and basic chemical urinalysis.

Imaging studies

  • Normal finding in radiography does not exclude a serious condition.
  • In primary health care, one should refrain from ordering lumbar x-ray examinations in patients with acute or subacute non-specific low back pain if there are no symptoms suggesting serious back disorder.
  • When instability of the spine is suspected, a plain x-ray in standing position is warranted (symptomatic spondylolysis and spondylolisthesis as well as degenerative states).
  • If special diagnostic examinations are needed, MRI is the first-line imaging investigation.
  • CT is a substitute investigation when planning for an emergency operation if MRI is not available or is contraindicated (e.g. patient with a pacemaker).

Neurophysiological investigations

  • ENMG may be useful in the situations listed below, if about 4 weeks have elapsed since the onset of nerve-based symptoms.
    • Demonstration of nerve root injury in cases where the clinical picture is not consistent with the evidence suggested by other investigations
    • The patient has neurological symptoms and signs but imaging studies do not reveal nerve root compression.
    • In chronic pain states the investigation may be indicated as a part of the comprehensive assessment.
    • The investigation is sometimes useful in prognostic assessment.
    • In differential diagnostics, if entrapment or damage of a nerve is suspected

Sciatic syndrome evd

Indications for emergency investigations and emergency surgery

  • Cauda equina syndrome
    • Sensory disturbance of the perineal (saddle) area, tone and contraction of the anal sphincter weakened
    • Urinary retention, faecal incontinence
  • Sudden paresis
    • Progressive or sudden loss of strength in the extensor or flexor muscles of the ankle or in the thigh muscle and, often, an associated sensory disturbance
  • Excruciating pain and a forced body position
  • A typical patient safety incident occurs if no adequate follow-up is organized and the progression of symptoms is not taken into account quickly enough, in which case further investigations are delayed.

Acute low back pain (duration less than 6 weeks) evd

  • If the pain is tolerable, if there are no signs of neurological deficits and if, based on patient history or findings, there is no reason to suspect a severe disease or a disease that requires specific treatment, the treatment is carried out based on the patient history and clinical examination as symptomatic therapy.
  • The benign nature and the good spontaneous healing tendency of the condition are emphasized to the patient.
  • Sick leave is considered on an individual basis. Short sick leave is usually sufficient. The aim is that the patient returns back to work after the sick leave.
  • If during the follow-up the symptom picture becomes worse, motor weakness appears and numbness expands, the patient should be referred, depending on the severity of the situation, within 0–7 days to a unit where an MRI scan can be, if necessary, performed.

Avoidance of bed rest and continuation of regular activities

Analgesics

Muscle relaxants

Physical activity, exercise therapy and supportive corset evd

Manipulation

Subacute low back pain (duration 6–12 weeks)

Investigations

  • If back pain is prolonged, further investigations for the confirmation of diagnosis, for the appraisal of treatment and, if needed, for the drawing up of a comprehensive rehabilitation plan should be performed after 6 weeks from the onset of symptoms, unless the patient's state has warranted diagnostic investigations already earlier. Depending on the symptom picture, consultation with a physiatrist, orthopaedist, rheumatologist or neurosurgeon is often needed to assess the diagnosis (special examinations), treatment, functional and working capacity and need for rehabilitation.
  • It is worthwhile to assess the patient's illness behaviour, exhaustion and depression in an interview and by pain drawings and questionnaires that the patient fills in him- or herself (e.g. Oswestry).

Treatment and rehabilitation evd

  • If a surgically treatable cause can be found (e.g. spinal stenosis, severe instability or disc herniation), the most feasible treatment method should be agreed on with the patient taking into account the severity of symptoms. This requires an assessment by a surgeon with experience in spinal surgery.
  • If the selected line of treatment is conservative and the prognosis of the disease good, treatment aims at rehabilitating the patient.
  • Treatment modalities that aim at active participation by the patient and at restoration of functional capacity are emphasized in relation to symptomatic treatment when the goal is to prevent chronicity of pain.
  • Thorough clinical examination, assessment of the patient’s situation and detailed instructions (brief intervention) decrease the number of sick leaves and the occurrence of impairing symptoms in subacute low back pain «Multidisciplinary biopsychosocial rehabilitation programs (MBR ) may offer some benefit compared with usual care for adults with subacute low back pain (LBP), but it is not clear whether MBR is better than some other type of treatment.»C.
  • Comprehensive and, if needed, multidisciplinary assessment of working capacity may reduce the need of sick leaves. Extended sick leaves increase the risk of long-term work disability.

Drug therapy

  • Basic approach to drug therapy is the same as with acute low back pain.
  • The adverse effects of analgesics in prolonged use must be considered especially in the elderly who are at risk of developing serious peptic ulcer perforations as a complication of NSAIDs. All NSAIDs can cause cardiovascular complications.
  • Antidepressants have so far not been shown to be better than placebo in the treatment of low back pain «Antidepressants may not be more effective than placebo in the management of patients with chronic low-back pain.»C, but antidepressants should be used if the patient is clearly depressive.
  • Benzodiazepines should be prescribed with caution and antipsychotics are not recommended for back pain.

When to consider elective surgery

  • Pain symptom that clearly impairs functional capacity and has lasted for over 6 weeks. It may be associated with sensory deficit, mild motor weakness or difficulties in emptying the bladder.
  • If the symptom picture is severe, the need for surgery may be assessed already earlier.

Chronic back pain (duration over 12 weeks)

  • In the treatment of back pain that has lasted for more than 3 months, the same guidelines apply as in the subacute phase. If needed, diagnostic investigations are carried out and a comprehensive plan concerning treatment and rehabilitation is drawn up anew in cooperation of physicians from different specialities.
  • Intensive physical training as a part of multidisciplinary rehabilitation is beneficial. Restoring of the working capacity requires measures directed at the work itself.

Drug therapy

Other therapies evd

Rehabilitation to improve functional and working capacity evd

  • Physical training and exercises that improve physical capacity reduce the number of sick leaves.
  • Sufficiently intensive and long-term resistance training (weight training) and exercise improving general physical condition (endurance training) reduce chronic back pain and improve function «Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain.»B.
  • Multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves functional capacity, work participation and quality of life and reduces pain in patients with chronic back pain.
  • Back massage when combined with therapeutic exercise and education may alleviate chronic back pain and improve function «Massage may be beneficial for patients with subacute and chronic non-specific low-back pain.»C.
  • Rehabilitation provided in a specialized rehabilitation facility may to some extent reduce the number of sick leaves and the use of analgesics in 3 years following the rehabilitation period.
  • Improvement of the working capacity of a person with chronic back problems requires also measures directed to the work itself. An approving attitude by the superiors and fellow workers towards functional impairment promotes the maintenance of working capacity of a person with back problems.

Patient educational material

Table 3. Recommended patient education in back pain (adapted from Waddell et al, 1996)
Type of back painPatient information
Common, unspecific back pain – convey a positive messageBack pain is very common.
No sign of a serious trauma or disease.
Recovery usually takes days or weeks at the most. In some patients, however, the symptoms may be prolonged.
There will be no permanent harm. Recurrences are common, but even then tendency for recovery is good.
Physical activity is beneficial. Too much rest is harmful. Moderate pain is not a sign of harmfulness.
Sciatic pain – convey a cautiously positive message.Provide appropriate information regarding symptoms and prognosis.
In most cases conservative treatment suffices, however, recovery usually takes 1–2 months. Good recovery is usually to be expected. In some patients, however, the symptoms may be prolonged. Recurrences are possible.
An MRI scan is warranted if the symptom picture becomes more severe or if a symptom suggesting dysfunction of a nerve root appears.
Possibly a serious disease – avoid conveying a negative message.Further investigations are needed for making a diagnosis. Often the results of these investigations are normal.
After the investigations a specialist will decide on the best possible therapy.
Excessive physical strain should be avoided until the investigations have been completed.

References

  1. Williams CM, Maher CG, Latimer J et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014;384(9954):1586-96. «PMID: 25064594»PubMed
  2. Cawston H, Davie A, Paget MA et al. Efficacy of duloxetine versus alternative oral therapies: an indirect comparison of randomised clinical trials in chronic low back pain. Eur Spine J 2013;22(9):1996-2009. «PMID: 23686477»PubMed